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

We decided that the Plan has to pay for the second hospital inpatient admission provided from July 30, 2019, to August 2, 2019.
You asked the Plan to pay for the second hospital inpatient admission. You say that the documentation supports that the complexity and high risk of the enrollee's presenting condition and medical history required an inpatient admission at the telemetry level of care. You also say that the enrollee's health and safety would have been directly threatened if care were provided at a lower level of care. The Plan denied your request. The Plan says that the readmission is related to the prior admission and can be avoidable.
The Plan follows Medicare rules. Medicare rules say that readmissions are denied if the readmission was medically unnecessary; and/or If the readmission resulted from a premature discharge from the same hospital.
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 second hospital inpatient admission. Our reviewer says that the review has determined that the readmission was medically necessary. Our physician reviewer found there was no documentation provided indicating that the readmission was a result from a premature discharge from the same hospital. 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 second hospital inpatient admission have been met. Therefore, we decided that the Plan has to pay for the second hospital inpatient admission provided from July 30, 2019, to August 2, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 2020.
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 were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on April 4, 2021.
You asked the Plan to pay for a supply allowance for a continuous glucose monitor. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for continuous glucose monitors and supplies have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 the enrollee performs blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a supply allowance for a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on April 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on March 8, 2021 by an out-of-network (OON) provider.
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 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 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 debridement services provided on March 8, 2021 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are at a high fall risk. The Plan denied your request. The Plan says you do not have daily skilled therapy or nursing 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 medically stable after recent treatment for a psoas abscess and osteomyelitis. There are no daily skilled nursing needs. Functionally, you are at a standby assist level for mobility and have do not require daily skilled therapies in an inpatient setting. The documentation does not support the need for an admission to a SNF 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 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: 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 IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ground mileage (A0425) and emergency ambulance transport
(A0427) provided on January 11, 2021.
You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that you would
like this claim to be reconsidered for payment. The Plan denied your request. The Plan says that the
information provided does not support the medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. 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 ground mileage and emergency
ambulance transport. Our reviewer says that the elements of the coverage criteria are satisfied. Our physician
reviewer found the record indicates that the enrollee had a fall at home and was conscious but non-verbal
which is her usual state. The enrollee was found supine and had evidence of knee injury. Our reviewer found
that the enrollee's blood pressure was noted to be 213/99. A similarly situated prudent layperson would believe
that without immediate medical attention there would be serious jeopardy to his or her health. Our physician
reviewer also found that the requested service is 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 ground mileage and emergency ambulance transport have been met.
Therefore, we decided that the Plan has to pay for the ground mileage (A0425) and emergency ambulance
transport (A0427) provided on January 11, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertiflex device (22869).

You asked the Plan to pre-approve a vertiflex device. You say that the service is medically necessary. The Plan denied your request. The Plan says the 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 a vertiflex device. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental and more research is needed to show its efficacy and safety. 

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 vertiflex device have not been met. Specifically, the vertiflex device is experimental and more research is needed to show its efficacy and safety. Therefore, we decided that the Plan does not have to pre-approve a vertiflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on
November 10, 2020.
You asked the Plan to pay for chiropractic manipulative treatment. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.
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 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 chiropractic manipulative treatment provided on
November 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 outpatient services provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on March 10, 2021.

You asked the Plan to waive the copayment for the arthrocentesis (20600). You say that this was just an office visit. 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 $260 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities. 

You have been asked to pay a $260 copayment for the arthrocentesis (20600). The arthrocentesis (20600) falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities benefit category. The provider's office is located on the property of a hospital. Medicare considers arthrocentesis a surgical procedure. 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 arthrocentesis provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal guard (D9940).

You asked the Plan to pay for a mouth guard. You say that you are in pain and cannot afford the mouth guard. The Plan denied your request. The Plan says this service is 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 an occlusal guard (D9940).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient detoxification services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee's condition has improved.

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 continued services. Our physician reviewer found that this enrollee does not meet the criteria for continued acute inpatient treatment from September 14, 2021 forward. She was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. She was not showing any threats the safety. She was not going through any withdrawals or complications from the use of alcohol and cannabis. Therefore continued services are not 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient detoxification services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for autonomic nervous system (ANS) function testing (95923, 95922, 95921, 95943) provided on February 9, 2021.

You asked the Plan to pay for ANS function testing. You say that this is supported in the records. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that the medical record documentation maintained by the performing provider must clearly support the medical necessity for ANS testing as well as the test reports and interpretation. 

We looked at the file and Medicare rules. The submitted medical records do not include test reports and interpretation. Based on this information, we decided that Medicare rules for coverage of ANS function testing have not been met. Therefore, we decided that the Plan does not have to pay for autonomic nervous system (ANS) function testing (95923, 95922, 95921, 95943) provided on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you have no other means of transporting yourself. The Plan denied your request. The Plan says the requested chair has added capabilities that are not needed for use in the home.
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under certain medical indications. We looked at the file and Medicare rules. In this case, medical records have not been provided that shows coverage criteria have been met for the requested scooter. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pharmacogenetic testing provided on September 1, 2020.

You asked the Plan to pre-approve the pharmacogenetic testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says if a laboratory evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure.

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, the pharmacogenetic testing, is being requested solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. This means that this extended panel was provided for screening purposes, and this type of testing is not among those covered by Medicare for screening. Therefore, we decided that the Plan does not have to pre-approve pharmacogenetic testing provided on September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on June 4, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transport. You say that this trip was medically necessary. The Plan denied your request. The Plan says these services were not medically necessary.

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 ground mileage and non-emergency ambulance transport. Our reviewer says that the ground mileage and non-emergency ambulance transport were not medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on June 4, 2021. Stretcher van would have been most appropriate. Our reviewer also 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 on this date of service. The enrollee's vitals were stable and there was no acute condition requiring treatment or monitoring during transport. 

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 ground mileage and non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of subcutaneous tissue (11042) rendered by the out-of-network (OON) provider on April 30, 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 debridement of subcutaneous tissue (11042) rendered by the out-of-network (OON) provider on April 30, 2021.