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

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) and a power seat elevation feature (E2300).
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that although there are three approved power options on this wheelchair, there is not a medical need to control these power options through the joystick.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 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 expandable controller, expandable controller harness and electronic connection. Our reviewer says that an expandable controller, expandable controller harness and electronic connection are not considered medically reasonable and necessary in this case. The documentation does not reveal that you require other types of proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Your strength in the upper extremities supports that you can control any power options through their own individual switches. Our physician reviewer found that your condition does not meet criteria for coverage of an expandable controller, expandable controller harness and electronic connection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) and a power seat elevation feature (E2300).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for hyponatremia,
weakness, and falling. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assist services provided on April 9, 2021.
You asked the Plan to pay for laparoscopy, surgical; cholecystectomy (47562AS). You say that the enrollee
had multiple services provided. The Plan denied your request. The Plan says this claim was paid on June 10,
2021.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 47562AS was paid. This claim is a duplicate. Medical records do not support the
service was provided more than once. Based on this information, we decided that Medicare rules for coverage
of laparoscopy, surgical; cholecystectomy (47562AS) have not been met. Therefore, we decided that the Plan
does not have to pay for a second claim of surgical assist services provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) and the chronic care management services (99490) rendered by the out-of-network (OON) provider on October 27, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) and the chronic care management services (99490) rendered by the out-of-network (OON) provider on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus vaccine received on June 19, 2021.
You asked the Plan to pay for the Tetanus vaccine. You say that your doctor stated this was medically
necessary to be in company with your newborn grandchild. The Plan denied your request. The Plan says the
services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tetanus
vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus vaccine received on June 19,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for outpatient diagnostic services and
specialist services provided on April 29, 2021.
You asked the Plan to waive these copayments. You say that the copayment applied in the total amount of
$76.53 for services rendered by the ophthalmologist is not correct. You stated that you had this service done in
the past and did not have to pay additional copayment for the diagnostic test. The Plan denied your request. The
Plan says this cost sharing was charged based on the services provided, the claim submitted by the provider and
the Plan contract agreement.
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 $50
copayment for outpatient diagnostics and $45 copayment for specialist services.
In both cases you have been charged less than the contractual copayment. You have been asked to pay the
correct amount based the providers claim and 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 waive the copayments charged for outpatient diagnostic services and specialist services provided on April
29, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair, adult size, patient weight capacity up
to and including 300 pounds (E1038).
You asked the Plan to pre-approve a transport chair. You say that you are very upset that this was denied
because it is medically necessary as you need to transport the enrollee to her appointments. The Plan denied
your request. The Plan says records do not show that the transport chair is used for appointments and outside
transportation.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 a transport chair. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation does not reveal an objective gait and neuromuscular exam or
objective progress reports that indicate that the patient has a mobility limitation that significantly impairs her
ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting,
feeding, dressing, grooming, and bathing in customary locations in the home. There is no evidence that the
mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker or that
the home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual
wheelchair that is provided. It is not clear that a manual wheelchair will significantly improve the patient's
ability to participate in MRADLs and the patient will use it on a regular basis in the home
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a transport chair have not been met. Therefore, we decided that the Plan does
not have to pre-approve a transport chair, adult size, patient weight capacity up to and including 300 pounds
(E1038).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99212 (office visit) and 00862 (anesthesia for
extraperitoneal procedure). Code 99212 is a column II code with a modifier indicator of 1 when billed with
column I code 00862. Code 99212 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine skilled nursing and fifteen physical therapy visits in the home for the enrollee.
You asked the Plan to pre-approve the visits. You say that this si medically necessary. The Plan denied your request. The Plan says teaching and education should have occurred with the previous visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 the visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the the enrollee's condition and/or prevent deterioration. There is no evidence of complex wound care, new enteral feedings, intravenous (IV) antibiotics, or other skilled nursing need. The enrollee had prior skilled nursing and should be educated in the medical management and condition at this point. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee had made improvement in activity tolerance and the Timed Up and Go test, and should be able to transition to an independent home exercise program. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve nine skilled nursing and fifteen physical therapy visits in the home for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and prophylaxis (D1110) provided on June 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that when you signed up with this Plan you were told that you would get three free cleanings per year with x-rays. You also say that you were given the name of this treating provider by a Plan representative, and were not advised that this provider was OON. The Plan denied your request. The Plan says the comprehensive oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that the total amount applied to your responsibility of $112.40 is correct, because these services were rendered OON. 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, comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 28, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. The contract also clearly states that you are responsible for the difference between the billed amount and allowed amount for dental services received OON. The record shows that you were not provided with the name of this treating provider by the Plan representative that you spoke with. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and prophylaxis (D1110) provided on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an
inpatient basis, at a SNF level of care as of October 10, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 13, 2020 to April 1, 2020.
You asked the Plan to pay for the home health services. You say that the RAP was acknowledged by the Plan. The Plan denied your request. The Plan says no valid RAP has been submitted.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for the home health services have not been met. The records show that an invalid value code was submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 13, 2020 to April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
May 25, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that your Evidence of Coverage
booklet states that x-rays are covered by the Plan. The Plan denied your request. The Plan says this service is
not listed as a covered benefit.
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. The only type of x-rays covered under your plan are bitewing x-rays
and periapical x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of
intraoral x-rays (D0210) provided on May 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530 X 44).
You asked the Plan to pre-approve the physical therapy visits. You say that you have gait instability worsened by right arm/shoulder problem. You state you have been working with your physical therapist for help with your shoulder/arm and now you have your gait issue because of everything. You state without physical therapy you cannot live your life on your own without help. The Plan denied your request. The Plan says notes do not show that the skills of a therapist are needed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 the physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested 44 units of therapy are not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530 X 44).