Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) device for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the requested device does not fit the Medicare definition of an implanted peripheral nerve stimulator.
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 the stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device does not (per the manufacturers' website and literature) does not require surgical placement. Given that surgical placement is not otherwise required this request does not appear to meet the requirements of the NCD for coverage of the device. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray, set-up portable x-ray equipment, and transportation of portable x-ray equipment and personnel provided on June 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the abdomen x-ray, set-up portable x-ray equipment, and transportation of portable x-ray equipment and personnel. You say that these services were performed on a non-skilled patient in a nursing home and do not require authorization. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that these services were not referred by a network provider, nor were they approved in advance.
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 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 abdomen x-ray, set-up portable x-ray equipment, and transportation of portable x-ray equipment and personnel provided on June 23, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) provided on April 6, 2021.
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for new patient domiciliary, rest home, assisted living visit
(99326) provided on May 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary, rest home, assisted living visit. You say that authorization was
not obtained prior to seeing this enrollee since it is the nursing facilities responsibility to get authorizations for
their patients. The Plan denied your request. The Plan says enrollee's must receive their medical services from
an in-network provider with the exception being urgent or emergent services. Non-emergent services with noncontracted
providers require prior authorization before services being rendered.
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 new patient domiciliary, rest home, assisted living
visit (99326) provided on May 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do not meet the 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 does not indicate that you use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided on February 17, 2021.
You asked the Plan to pay for the eye exam and refraction. You say that the medical records support the eye exam was routine and the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a participating provider with the Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from the Plan's network provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and refraction have not been met. Specifically, the services were received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 22, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The documentation does not support that the laboratory services provided would likely impact the therapeutic decision-making in the clinical management of the enrollee. This means that the laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on March 23, 2021.

You asked the Plan to reduce the copayment for the specialist office visit. You say that the provider is in-network, and you should be charged a $35 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 $60 copayment for each out-of-network specialist office visit.

You have been asked to pay a $60 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider was out-of-network. 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 specialist office visit provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic
CGM.
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, require frequent selfadjustment
of insulin dosage based on the blood glucose testing results, have had an in-person visit with their
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore,
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
April 18, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you have a permanent foley catheter
and you were experiencing painful urinary retention in the early morning hours of April 18, 2020. You said
that you usually have your catheter changed by your home health agency, but they are not a 24-hour service, so
you could not call them to do this. You also stated that because urgent care centers are not equipped to perform
this service, you had to go to the ER. You stated that you should not have to pay the ER copayment because
you had no other option. The Plan denied your request. The Plan says you were charged this copayment
correctly. The Plan says that because the allowed amount for this service ($80.72) is less than your copayment
obligation, you are responsible for the full allowed 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 $90
copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason
for the ER visit. 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 the emergency room (ER) visit
you had on April 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the porcelain crown (D2740) for tooth # 4 provided on May 8, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that you had no idea the crown used different materials. You say that you were not aware. You also say that you believe you should only be responsible for 50% of the initial amount that was quoted. The Plan denied your request. The Plan says crowns are covered with a 50% coinsurance. The Plan says you signed a financial agreement with the provider acknowledging to the cost of the upgraded materials. The Plan also says that upgraded materials are 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file shows that you signed a financial agreement with the provider acknowledging the cost of the upgraded materials. Therefore, we decided that the Plan does not have to pay an additional amount for the porcelain crown (D2740) for tooth # 4 provided on May 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tavalisse for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tavalisse for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95806 or 95810).
You asked the Plan to pre-approve the sleep study. You say that the enrollee has a prior diagnosis of sleep apnea. You also say that the enrollee's last test was 30 years ago. The Plan denied your request. The Plan says repeating this test may be useful in certain cases such as if the enrollee has had more than a 10% change in weight or had surgery on an upper airway. The Plan also says that this is not shown within the documentation provided.
The Plan follows Medicare rules. Medicare rules say that prior to sleep testing, the patient has a face-to-face clinical evaluation by the treating physician to assess the patient for Obstructive Sleep Apnea (OSA) which must include an Epworth Sleepiness Scale. 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 sleep study. Our reviewer says that the sleep study is not medically reasonable and necessary. Our physician reviewer found the case file does not contain documentation of an Epworth Sleepiness Scale.
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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study (95806 or 95810)
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

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 ten (10) additional PT 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 that the additional requested therapy is
not generally accepted as specific and effective therapy for your condition beyond what was approved by the
health Plan. You have had prior therapy of twenty (20) outpatient visits 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 can transition to a home exercise program. You feel more comfortable ambulating on uneven
terrain. You are walking household distances and have not been using the cane in the community. You can
continue range of motion exercises on your own for your hip. There is no evidence that the physician signed
the September 17, 2021 therapy treatment plan and that you require ongoing skilled therapy. 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 ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance services.
You asked the Plan to pre-approve ambulance services. You say that ambulance transport is medically necessary. The Plan denied your request. The Plan says that there is no medical need for you to require an ambulance.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that ambulance services are not medically reasonable and necessary. The documentation does not support that other means of transport (such as stretcher van) are contraindicated. The documentation does not support that you need the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. You are hemodynamically stable and at chronic baseline. Our physician reviewer found that your condition does not meet Medicare criteria for ambulance 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transports (A0428-RJ, A0428-JR, A0428-JH) and ground mileage (A0425-RJ, A0425-JR, A0425-JH) provided from March 15, 2021, to March 17, 2021.

You asked the Plan to pay for the transportation services. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance services are not covered.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 pay for the transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van) were contraindicated for the enrollee from March 15, 2021, to March 17, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport from March 15, 2021, to March 17, 2021. Therefore, the reviewer found that the ambulance transport was not medically reasonable and necessary for 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 transportation services have not been met. Specifically, the file does not support that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transports (A0428-RJ, A0428-JR, A0428-JH) and ground mileage (A0425-RJ, A0425-JR, A0425-JH) provided from March 15, 2021, to March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from February 22, 2021, to February 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not provided.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider for the dates of service in question. Without records, it cannot be confirmed that Medicare coverage criteria have been met.
Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided from February 22, 2021, to February 26, 2021.