Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300 and E2311).
You asked the Plan to pre-approve the power wheelchair features. You say that these features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but not the seat elevation feature (E2300) or electrical connection device (E2311) are not covered.
The Plan must follow Medicare rules. Medicare rules say that a seat elevator (E2300) does not serve a primary medical purpose and is statutorily non-covered. Since the seat elevator is not approved, there is no need to control two or more power features through the joystick, so the electric connection (E2311) is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair features have not been met. Therefore, we decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300 and E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the MRI provided on June 24, 2021.
You asked the Plan to reduce the copayment for the MRI. You say that the MRI was done at a freestanding facility, and you should have a $180 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for in-network advanced imaging services at a primary care physician or specialist's office.
You have been asked to pay a $225 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the place of service code is an office. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the MRI provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the CGM should be covered. The Plan denied your request. The Plan says you do not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97813, 97814) provided from June 14, 2021, to June 22, 2021.
You asked the Plan to pay for acupuncture services. You say that this should be covered because you have back pain. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, no records have been submitted to show that your lower back pain is chronic. Therefore, we decided that the Plan does not have to pay for acupuncture services (97813, 97814) provided from June 14, 2021, to June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission.
You asked the Plan to pre-approve an inpatient psychiatric admission. You say that an inpatient psychiatric level of care is medically necessary. The Plan denied your request. The Plan says an inpatient psychiatric level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an inpatient psychiatric admission. Our reviewer says that an inpatient psychiatric level of care is not medically necessary. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative with care. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 21, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator with the power supply and components provided on April 9, 2021 to April 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the oxygen equipment. You say that you needed to pay out of pocket for these expenses and would like reimbursement. The Plan denied your request. The Plan says the provider was an out of network provider and prior authorization is required for out of network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal.
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator with the power supply and components provided on April 9, 2021 to April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) provided on January 9, 2020.
You asked the Plan to pay for the short-latency somatosensory evoked potential study. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says only the facility may be paid for these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 95938 is not supported in the record. Specifically, the record indicates that this member was inpatient on the billed date of service, meaning that this provider serviced a facility with an existing POS code. Payment for the technical component of this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) provided on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure machine (CPAP).
You asked the Plan to pre-approve the CPAP. You say that the CPAP you have has been recalled; you require a new one. The Plan denied your request. The Plan says that the request is not approved because equipment is already available to the beneficiary.
The Plan must follow Medicare rules. Medicare rules say that the MAO is responsible for maintaining continuity of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME item, including when the item needs to be repaired or replaced. We asked our reviewer to review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CPAP. Our reviewer says that the requested items/services are considered reasonable and necessary in this case. Our reviewer found Medicare rules say that item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). There has been a class I FDA recall on the device, which is the most serious. There is not a way of knowing if this enrollee's device is affected. The enrollee was instructed to discontinue use, and that interrupted use can pose a risk to the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure machine (CPAP).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete dentures. You say that the enrollee's dentures were accidentally thrown away, and the enrollee cannot eat without them. The Plan denied your request. The Plan says the enrollee's denture benefit was exhausted on August 10, 2018 and will not be available again until August 2023.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary denture and mandibular denture are each limited to one procedure every five plan years. The record shows that the enrollee received a complete maxillary denture (D5110) and mandibular partial denture (D5214) on August 10, 2018 and the enrollee's maxillary and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove an automatic blood pressure monitor (A4670).
You asked the Plan to preapprove the blood pressure monitor. You say that this is important preventative
measure for the enrollee. The Plan denied your request. The Plan says a automatic blood pressure monitor is
not a covered item by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension. The automatic blood pressure monitor defined by code A4670
is not a covered service.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to preapprove an automatic blood pressure monitor (A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Freestyle Libre 2 continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the CGM should be covered The Plan denied your request. The Plan says you do not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections with frequent adjustments.
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultra lightweight manual wheelchair (K0005).
You asked the Plan to pre-approve the lightweight manual wheelchair. You say that your current electric wheelchair is in need of repairs and you cannot use it in your house. The Plan denied your request. The Plan says it will not cover back-up wheelchairs.
The Plan must follow Medicare rules. Medicare rules say that backup chairs are denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lightweight manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve ultra lightweight manual wheelchair (K0005).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-precision attachment abutments (D6052 x 2), a
connecting bar (D6055), and copings (D2975 x 4).
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan
denied your request. The Plan says semi-precision attachment abutments are not listed as covered services. The
Plan says that connecting bar is not listed as a covered service. The Plan also says that copings are not listed as
covered services either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
semi-precision attachment abutments (D6052 x 2), a connecting bar (D6055), and copings (D2975 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three retainer crowns (D6740 x3).
You asked the Plan to pre-approve the retainer crowns. You say that the enrollee needs a bridge for tooth #'s 19, 20, and 21 because of active primary caries. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three retainer crowns (D6740 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 29.

You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary.
The Plan denied your request. The Plan says core build up is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core
build up (D2950) for tooth # 29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that these services are medically necessary. The Plan denied your request. The Plan says you must first get a referral from your primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. In this case, the Plan has confirmed that you have not yet received medical services from your primary care physician. Therefore, there are no medical records available to support the medical necessity of the requested services. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more help than what he is getting. The Plan denied your request. The Plan says the IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.