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

 We decided that the Plan does not have to pre-approve an office visit with a specialist (99214) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit with a specialist. You say that you are not confident that the Plan can best redo your hiatal hernia surgery. The repair performed by the previous provider failed in less than a week and you ended up at Urgent Care soon after your surgery. You also say you have been suffering since your surgery in February and you still cannot keep food down, you have chest pain, and pain in your left arm. The Plan denied your request. The Plan says the provider you are requesting is out-of-network and you have been redirected to an in-network provider.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit with a specialist (99214) to be provided by an out-of-network (OON) provider.   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an over bed table.  You asked the Plan to pre-approve the table. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an over bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra wide commode chair (E0168) for the enrollee.

You asked the Plan to pre-approve the commode. You say that this is medically necessary. The Plan denied your request. The Plan says the information received indicates that the enrollee has the same or similar durable medical equipment in good condition and less than five years old.

The Plan must follow Medicare rules. Medicare rules say that if an E0168 commode is ordered and the beneficiary does not weigh more than 300 pounds, it will be denied as not reasonable and necessary. 

The records show that the enrollee's weight is 265 pounds. Patients must weigh 300 pounds or more to indicate coverage for this type of commode. Based on this information, we decided that Medicare rules for coverage of the commode have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra wide commode chair (E0168) for the enrollee.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve repeat treatment with Zilretta.  You asked the Plan to pre-approve repeat treatment with Zilretta. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested treatment is not medically accepted or supported as prescribed.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 repeat treatment with Zilretta. Our reviewer says that the requested treatment is medically reasonable and necessary in this case. Our physician reviewer found that the FDA updated the requested drug's label in 2020 to remove the limitation that the drug is not intended for repeat use and modified the label to state that the efficacy and safety of repeat administration of Zilretta have not been demonstrated. The requested drug is being used for its current FDA-labeled indication. The FDA-approved label does not preclude the repeat use of Zilretta. Additional administration of the requested drug has been shown to result in a similar magnitude and duration of clinical benefit as the first injection and has been shown to be well-tolerated. Repeat administration has been shown to be well-tolerated, with no unexpected adverse effects, post-injection flares, or radiographic evidence of deleterious effects on cartilage or other elements of joint structure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat treatment with Zilretta have been met. Therefore, we decided that the Plan has to pre-approve repeat treatment with Zilretta.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the BioWave system for the enrollee.  You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered accepted by the medical community.  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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational device and the progress note does not supports its use. The request is not medically reasonable or 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 the system have not been met. Therefore, we decided that the Plan does not have to pre-approve the BioWave system for the enrollee.
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 you are not ready to go home, and you need additional assistance and care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. There is no documentation that you have complex medical, nursing, or rehabilitation needs that require the level of care provided in an IRF. You can receive the services you need in a less intensive setting.  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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care, such as a skilled nursing facility, home with home health services, or outpatient therapy.  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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (93306) provided on August 9, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 up to a $50 copayment for each Medicare-covered outpatient diagnostic procedure and test in an office setting or imaging center and up to a $175 copayment for each Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.   You have been asked to pay a $175 copayment for the Medicare-covered outpatient diagnostic test provided in an outpatient hospital facility. 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 transthoracic echocardiography (93306) provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (tens) device (E0730) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the TENS device. You say that your doctor authorized a prescription for a home e-stim device and you believe that the Plan should provide the equipment that the doctor ordered. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (tens) device (E0730) to be provided 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 high frequency chest wall oscillation device (E0483).

You asked the Plan to pre-approve the high frequency chest wall oscillation device. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for hospital infusion therapy visits provided from February 18, 2021, to March 4, 2021.  You asked the Plan to waive the copayments for outpatient hospital visits. You say that $20 seems the most you should have to pay for each of these infusions. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $295 copayment per visit for infusion therapy provided at an in-network outpatient hospital. The allowed amount of each visit is $204.95, which is less than the $295 copayment amount. There were 14 visits, resulting in a total copayment amount of $2,869.30.  You have been asked to pay the allowed amount of $204.95 per visit, which is less than the $295 copayment for outpatient hospital visit. Outpatient hospital visits fall within the Outpatient Surgery and Other 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 copayments for hospital infusion therapy visits provided from February 18, 2021, to March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair and accessories to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested items.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injection (ESI) services.

You asked the Plan to pre-approve ESI services. You say that the clinical documentation provided supports the need for the injection services being requested. The Plan denied your request. The Plan says the notes do not show that the enrollee had special pictures that match her symptoms. The Plan says that the requested injection services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that ESI services are covered for certain medical indications.

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 ESI services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of arthritis and back pain related to a T12 fracture. The magnetic resonance imaging (MRI) demonstrates an acute compression fracture of the T12 vertebral body with 50-60% loss of height and prior compression fracture of L1 with prominent retropulsion resulting in mild central canal stenosis at L1. There is mild multi-level disc desiccation. There are normal central canal and intervertebral neural foramina noted at the T1-T12 levels. The provider has requested a thoracic epidural steroid injection at T11-T12. There is no documented disc herniation, osteophyte/osteophyte complexes, or severe degenerative disc disease producing foraminal or central spinal stenosis. There is also no documentation in the history, on exam, or MRI findings supporting thoracic radiculopathy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ESI services have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injection (ESI) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 199.    You asked the Plan to pay for the inpatient hospital services billed with DRG 199. You say that you received reimbursement on DRG 201 which was inappropriately down coded. You also say that you would like the claim updated with the correct Medicare rate for DRG 199 and reprocess it for payment. The Plan denied your request. The Plan says DRG 199 is not supported as the diagnosis of Acute respiratory failure with hypoxia.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with J96.01, defined as Acute respiratory failure with hypoxia. 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 inpatient hospital services billed with DRG 199. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found the review indicates that there was no documentation of respiratory failure on presentation or during the admission. The review has determined that the medical records did not support the billing of acute respiratory failure with hypoxia.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 199.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 16, 2021, to August 18, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered as you feel like they were done for financial gain by the Plan. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $180 copayment per day for days 1-7 for Inpatient hospital care.        You have been asked to pay a $180 copayment per day for two days of inpatient hospital care ($180 x 2 = $360). 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 inpatient hospital care provided from August 16, 2021, to August 18, 2021.   Your complaint about the Plan potentially discharging you for financial gain 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a placement of intra-socket biological dressing (D7922) and four bone replacement grafts for ridge preservation (D7953 x4).

You asked the Plan to pre-approve the placement of intra-socket biological dressing and bone replacement grafts. You say that you need this work done as soon as possible and it is medically needed for the bone grafts. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a placement of intra-socket biological dressing (D7922) and four bone replacement grafts for ridge preservation (D7953 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.