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

We decided that the Plan does not have to pre-approve a crutch substitute (E0118) for the enrollee.

You asked the Plan to pre-approve a crutch substitute.. You say that the member cannot walk with this device. The Plan denied your request. The Plan says that this is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch substitutes (E0118). 

We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical equipment in the State of Florida has decided that the crutch substitute coded as E0118 is not medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a crutch substitute. have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee does not have skilled nursing or therapy needs that need to
be provided on a daily basis as an inpatient only status.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a left total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is approved for a left total shoulder arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97112, J3490, and G0283) provided on May 10, 2021.
You asked the Plan to pay for the Sanexas device and vitamin injections. The Plan denied your request. The Plan says Medicare does not cover Prolotherapy.
The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. The rules also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. We looked at the file and Medicare rules. After review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by a Nurse Practitioner who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of the Sanexas device and vitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97112, J3490, and G0283) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the filling (D2391) provided on September 20, 2021.  You asked the Plan to pay for the dental service. You say that you were not aware that this would not be covered by the insurance. The Plan denied your request. The Plan says there is a $500 allowance for preventive and comprehensive dental services per calendar year. The Plan also says that the allowance has been exhausted.  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 allowance has been exhausted. The record shows that the Plan paid $106 for services rendered on March 11, 2021, $52 for services rendered on June 23, 2021, and $342 for services rendered on June 28, 2021. $106 + $52 + $342 = $500 Therefore, we decided that the Plan does not have to pay for the filling (D2391) provided on September 20, 2021.
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 requires IRF services. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and to pay more for the resin-based composites of one surface (D2391) and resin-based composites of two surfaces (D2392) provided on January 21, 2021, and March 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the crown or pay more for the resin-based composites. You say that you would like to appeal these services. The Plan denied your request. The Plan says the crown is not a covered benefit. The Plan also says that you are responsible for a 50% coinsurance for the resin-based composites.
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, crown (D2740) is not among those covered under this benefit. The contract also says that you are responsible for a 70% coinsurance for resin-based composites that are received OON. The resin-based composites were processed by the Plan showing you only owed a 50% coinsurance for each, which is less than the coinsurance amount provided in the contract. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and to pay more for the resin-based composites of one surface (D2391) and resin-based composites of two surfaces (D2392) provided on January 21, 2021, and March 22, 2021 by an out-of-network (OON) provider.
Your complaint about your issues with the Plan and the billing department is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiologic examination, chest (71045) set-up of portable x-ray equipment (Q0092) transportation of portable X-ray equipment and personnel (R0070) provided on June 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the portable x-ray services. You say that tests are supposed to be furnished withing 24 hours, which do not allow you ample time to verify eligibility and process authorization beforehand. 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 non-contracted 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 radiologic examination, chest (71045) set-up of portable x-ray equipment (Q0092) transportation of portable X-ray equipment and personnel (R0070) provided on June 11, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on May 17, 2021.
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 laboratory services rendered by the out-of-network (OON) provider on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.

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 services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. The services are therefore not reasonable or medically necessary.

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 a Vertiflex Superion spacer
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on April 19, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on April 19, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy rendered on March 4, 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 covered.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy rendered on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Impella device procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested service is not medically necessary.
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 requested services. Our physician reviewer found that in this case, the Food and Drug Administration (FDA) has stated the Impella System is a temporary ventricular support device indicated for use during high-risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease and depressed left ventricular ejection fraction, when a heart team, has determined high risk PCI is the appropriate therapeutic option.
The record indicates that the enrollee requires coronary angioplasty with stent placement. The enrollee has an ejection fraction of 55-60%. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Impella device procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stay at a SNF provided on July 28 to August 13, 2021.
You asked the Plan to waive the copayment for a stay at a SNF. You say that you cannot afford the assessed copayment. The Plan denied your request. The Plan says the correct copayment was applied.
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 $184 copayment for each day of days 21 to 100. Your contract also says that a benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. In this case, the case record shows that you previously received SNF care for 19 days in June 2021 within the same benefit period. You have been asked to pay $2,760, or a $184 copayment for days 21 to 35 of SNF care received within a single benefit period, for a 16-day stay at a SNF. 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 stay at a SNF provided on July 28 to August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 1, 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 covered. 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 test 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 rendered on April 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for family psychotherapy services (90847) provided on August
26, 2021, by an OON provider.
You asked the Plan to pay for psychotherapy services. You say that the services have always been paid and
suddenly, the claim was denied. 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. Nonemergent
services with non-contracted 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 family psychotherapy services (90847) provided
on August 26, 2021, by an OON provider