Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be admitted to LTACH because of their acute needs. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with a bowel obstruction and underwent repair of parastomal hernia. The enrollee has had a prolonged hospital course, including hypoxic respiratory failure. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to hold you harmless for outpatient mental health services provided on August 26, 2020, to September 11, 2020.
You asked the Plan to hold you harmless for outpatient mental health services. You say that you have been seeing this provider since 2012 and you have never had issues with payments in the past. The Plan denied your request. The Plan says that services are not covered per the member's benefit package.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for outpatient mental health services by a contract provider. The file does not show that the Plan provided notice that outpatient mental health services would not be covered. Under Medicare rules, this means outpatient mental health services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for outpatient mental health services provided on August 26, 2020, to September 11, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397), a
lumbar-sacral orthosis (L0650) and a a wrist-hand orthosis (L3916) provided to the enrollee on January 28,
2021.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a knee orthosis with suspension sleeve (L1851, L2397), a lumbar-sacral orthosis (L0650) and a a wristhand
orthosis (L3916) provided to the enrollee on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0637) and a shoulder brace (L3960).

You asked the Plan to pay for the back and shoulder brace. You say that the claim should be paid. The Plan denied your request. The Plan says there was insufficient support from the medical record for the braces.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. 

The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a back brace (L0637) and a shoulder brace (L3960).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home visit provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that you did not know the services needed to have a prior authorization. The Plan denied your request. The Plan says services must be obtained from an in-network provider unless there is an emergency or a 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 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 rest home visit provided on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered on February 15, 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 procedure code 97014 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
We looked at the file and Medicare rules. Billed procedure code 97014 (electrical stimulation therapy) has a
status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have
to pay for the electrical stimulation rendered on February 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. All services that would be provided in the LTACH are being provided in the current acute care setting which is already approved. Therefore, transfer to an LTACH is not medically necessary in this case.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on May 27, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you have had these lab services done for thirty years and never had to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. 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 waive the copayment for lab services you received on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on May 17, 2021.
You asked the Plan to waive the copayment for a medical eye exam. You say that you were initially charged $50, and the provider refunded you $40 but you thought you would get a full refund. You also say that the charge was unexpected because the provider did not tell you that you were diagnosed with any condition. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $10 copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.
You have been asked to pay a $10 copayment for a medical eye exam. The EOC confirms that $10 is the required copayment for this service. A medical eye exam falls within the vision care benefit category. 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 waive the copayment for a medical eye exam (92014) provided on May 17, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve bone and/or joint imaging of the whole body.

You asked the Plan to pre-approve bone and/or joint imaging of the whole body. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 bone and/or joint imaging of the whole body. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found review of the computed tomography (CT) abdomen and pelvis report of April 14, 2021 shows sclerotic foci within the left hip where metastases have been included in the differential. As such it is important to assess the nature of these lesions and bone scan with single-photon emission computerized tomography (SPECT) will give the most information allowing for customizing treatment for this patient with prostate cancer. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone and/or joint imaging of the whole body have been met. Therefore, we decided that the Plan has to pre-approve bone and/or joint imaging of the whole body.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you are in a lot of pain. The Plan denied your request. The Plan says you do not meet the guidelines.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

We looked at the file and the rules. The records do not show that you suffer from diabetic foot disease or that you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. 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. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan of the abdomen and pelvis. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended at this time. 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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, advanced life support, nonemergency
transport, level 1 (A0426) and ground mileage, per statute mile (A0425) provided March 12, 2021.

You asked the Plan to pay for the non-emergency ambulance transport. You say that the transport was
medically necessary. The Plan denied your request. The Plan says you did not obtain prior authorization for the
transport and therefore it is not covered.

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 the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage, per statute mile (A0425) provided March 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection into the spinal canal (62321) provided on November 19, 2020.

You asked the Plan to waive the copayment for an outpatient surgical procedure. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $275 copayment for an outpatient procedure. The EOC confirms that $275 is the required copayment for this service. An outpatient surgical procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 waive the copayment for an injection into the spinal canal (62321) provided on November 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are losing strength in your hands. The Plan denied your request. The Plan says you have no daily skilled nursing or therapy needs.

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 services. Our physician reviewer found that you are at a modified independent level with ambulation using a rolling walker. You participate in physical therapy twice a week with improvement and decreased pain. You do not require the skilled nursing services of a professional nurse to provide medically necessary treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF needs. Your functional level does not require the skilled therapy services of a qualified therapist to provide medically necessary treatment in a SNF. The patient does not require skilled nursing or skilled therapy services on a daily basis in a SNF. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) and non-intravenous conscious sedation (D9248) provided May 11, 2021.

You asked the Plan to pay for the removal of torus mandibularis and non-intravenous conscious sedation. You say that these services are necessary for a denture placement. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 pay for the removal of torus mandibularis (D7473) and non-intravenous conscious sedation (D9248) provided May 11, 2021.