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

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic compression appliances (E0667, E0668).  You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are appealing the decision to not cover the compression pump based on the necessity as outlined in the standard of care for lipedema/lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic compression appliances (E0667, E0668).
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan states the services the enrollee needs could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving, but still requires additional short-term acute care hospital 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. Transfer to the LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.  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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that you need assistance with bed mobility, ambulation, and transfer. You state that prior to Coronavirus (Covid) infection, you were going to dialysis three (3) times a week independently. You state it is about five hundred (500) feet to and from the street. You state you are only walking ten (10) feet, and you need assistance with using the bathroom because you are weak and have low endurance, you are easily fatigued, and now you need assistance with lower body dressing. You state you have no help at home. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria.  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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on March 11, 2021.  You asked the Plan to pay for the office visit. You say that you have provided proof of payment and should be reimbursed. The Plan denied your request. The Plan says there is no valid referral on file therefore, we cannot approve your request.  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 office visit provided by an out-of-network provider on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing (CPT code(s): 81292 and 81321) provided to the enrollee on June 1, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  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.  As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and is a test not currently satisfactorily described by any existing CPT code; to report a Comprehensive Genomic Profile (CGP) screening service providers should use 1-unit of CPT code 81479 (used for the entire bundled multi-test panel), in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test. Coverage of Comprehensive Genomic Profile (CGP) is limited to one test per specimen and precludes the use of any other molecular testing on the specimen. Medicare says do not list unbundled separate codes on the claim. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing (CPT code(s): 81292 and 81321) provided to the enrollee on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have the coinsurance for an automatic external defibrillator (K0606) provided on July 28, 2021.  You asked the Plan the coinsurance for the automatic external defibrillator. You say that the services should be covered as the enrollee was not made aware of the cost-sharing that would apply beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the item 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.        The enrollee has been asked to pay a 20% coinsurance for the automatic external defibrillator (the allowed amount is $3168.69 x 20% = 633.73). Automatic external defibrillators fall within the Durable medical equipment (DME) and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have the coinsurance for an automatic external defibrillator (K0606) provided on July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lantus Solostar.  You asked the Plan to pre-approve the Lantus Solostar. You say that you would like reconsideration because the requested drug is medically necessary for the treatment of your condition. The Plan denied your request. The Plan says the requested drug is self-administered.  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 Lantus Solostar.   Benefits for the Lantus Solostar may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement dentures.  You asked the Plan to pre-approve dentures. You say that your old dentures do not fit, and you need new ones. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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. The Plan covers dentures when the existing dentures were inserted at least 60 months prior to the replacement.  We looked at, the file and Medicare rules. In this case the Plan provided documentation showing that dentures were previously covered on July 28, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of dentures would be exceeded with the requested dentures. Therefore, we decided that the Plan does not have to pre-approve replacement dentures.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve methylphenidate.  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 self-administered drugs are not covered.  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 methylphenidate.     Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).  You asked the Plan to pre-approve additional mileage for routine transportation. You say that you want to see this provider. The Plan denied your request. The Plan says your benefit only allows 100 one-way trips with each one-way trip not exceeding 50 miles of driving distance.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 66 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay an additional amount, up to the Plan's eyewear benefit amount of $100 for eyeglasses provided on August 16, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says that the claim processed correctly.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan covers a routine eyewear benefit with a $100 allowance combined in and out of network toward the purchase and fitting of eyeglasses and a pair of lenses or contact lenses (1 per calendar year). Therefore, we decided that the Plan has to pay an additional amount up to the Plan's eyewear benefit amount of $100 for the eyeglasses provided on August 16, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 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 were not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heel lift.  You asked the Plan to pre-approve these services. You say that having an unproportioned leg length is difficult. The Plan denied your request. The Plan says the services are not covered.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a heel lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Frequency Specific Microcurrent (FSM) therapy.  You asked the Plan to pre-approve FSM therapy. You say that you were advised by your doctor that this therapy would be the best fit. You say that if you were to have surgery to remove the scare tissue it would create new scar tissue and maybe even worsen the symptoms you currently have. The Plan denied your request. The Plan says FSM therapy is a non-covered benefit due to lack of medical literature supporting the effectiveness of this therapy.  The Plan must follow Medicare rules. Medicare rules say that FSM therapy is non-covered.   We looked at the file and Medicare rules. We decided that the Plan does not have to pre-approve Frequency Specific Microcurrent (FSM) therapy.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the open treatment of a femoral fracture (27236) provided on March 5, 2021.  You asked the Plan to pay for the open treatment of a femoral fracture. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We asked our coder 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 open treatment of a femoral fracture. Our reviewer says that CPT code 27236 does not meet criteria for billing or reimbursement consideration. Our reviewer found per the CPT code description "Open treatment of a femoral fracture".  This procedure involves stabilizing broken bones with surgical screws, nails, rods, or plates, and is usually for fractures in which bones can be properly aligned.  The operative report documents the femur was inspected and there was no sign of acute fracture.  Operative report describes a partial hip replacement. In this case, the procedure documented was reported incorrectly and would not be covered.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the open treatment of a femoral fracture have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of a femoral fracture (27236) provided on March 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a screening mammogram to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a screening mammogram. You say that you would like to see this provider who you have been with for the past 12 plus years. The Plan denied your request. The Plan says the requested services can be provided by a 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 a screening mammogram to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310).  You asked the Plan to pre-approve a dental consultation. You say that you would like this service covered. 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 pre-approve consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair (E0240).  You asked the Plan to pre-approve a shower chair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that your pain has not subsided over a two-month period. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    We looked at the file and the rules. The records do not show that you suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.