Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the full face mask (A7030), replacement face mask interface (A7031), headgear (A7035), tubing (A7037), disposable filter (A7038), non-disposable filter (A7039), and water chamber for humidifier (A7046) provided on April 22, 2021.  You asked the Plan to pay for the positive airway pressure device supplies. You say that the enrollee was not in hospice on this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on April 8, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the full face mask (A7030), replacement face mask interface (A7031), headgear (A7035), tubing (A7037), disposable filter (A7038), non-disposable filter (A7039), and water chamber for humidifier (A7046) provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 and requires only short-term additional acute
care services that can be safely administered at the current facility for now. There are no services at the
LTACH that the enrollee requires that are not already available and covered at the current facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 somewhat unstable at this time and requires only short-term additional acute care services that can be safely administered at the current facility for now. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   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 long term acute care hospital (LTACH) 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 the records provided support the need for IRF care.
The Plan denied your request. The Plan says the records do not indicate that the enrollee is able to tolerate and
benefit from 3 hours of therapy per day.
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 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. The
enrollee was admitted for surgical repair of an ankle fracture after a fall. The enrollee's medical problems are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional rental months for the oxygen concentrator (CPT code E1390).  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Our records indicate you received the oxygen concentrator (CPT code E1390) on August 24, 2018. You have used 36 months of this service. Authorization for oxygen equipment is limited to 36 monthly rental payments. Payment for accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included in the rental allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance for stationary equipment (E0424, E0439, E1390, E1391). There is no indication or documentation stating a replacement item(s) is being requested. At this time no further authorizations can be provided. Therefore, we decided that the Plan does not have to pre-approve additional rental months for the oxygen concentrator (CPT code E1390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continuous glucose monitor and related supplies provided on January 7, 2021.  You asked the Plan to pay for a continuous glucose monitor and related supplies. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met the service at issue was related to a prohibited telemarketing contact.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.    We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and related supplies have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor and related supplies provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on September 13, 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 drug test (G0482) rendered by the out-of-network (OON) provider on  September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit in a specialist office provided on October 6, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that your medical plan says there is no copayment for outpatient urgent care centers. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for urgently needed services provided in a specialist office.   The file shows that the provider is listed as an office, and not an urgent care center. Therefore, you have been asked to pay a $50 copayment for the urgent care visit.  The urgent care visit falls within the Urgently Needed Services 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 copayment for an urgent care visit in a specialist office provided on October 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for individual psychotherapy service (90832) provided August 17, 2021.  You asked the Plan to pay for the psychotherapy service. You say that you are requesting for review of the documents and process of the claim for payment. The Plan denied your request. The Plan says that the services are not supported without the required documentation.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy service have been met. Therefore, we decided that the Plan has to pay for individual psychotherapy service (90832) provided August 17, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic services provided on July 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for diagnostic services. You say that the facility is responsible for obtaining authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.  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 diagnostic services provided on July 15, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9752, and C9753), for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9752, and C9753), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services coded 76376 provided on September 14, 2021.  You asked the Plan to pay for the 3D rendering with interpretation and reporting services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76376 is a column II code to column I code 78306. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services coded 76376 provided on September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sleep study (95810) provided on August 21, 2021.  You asked the Plan to pay for the sleep study. You say that the service is medically necessary. The Plan denied your request. The Plan says documentation to support the service was not provided. The Plan also says that the claim was processed correctly.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sleep study have not been met. Specifically, the file does not include documentation that supports that the sleep study was necessary despite multiple attempts from the plan. Therefore, we decided that the Plan does not have to pay for the sleep study (95810) provided on August 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hand therapy services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve hand therapy services. You say that you need occupational and physical
therapy services for your hand. You also say the provider's office says they are in-network with your Plan. The
Plan denied your request. The Plan says the requested provider is OON with your Plan. The Plan also says
there are in-network provider(s)within a reasonable distance from your location that can provide this service.
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. The records provided for review do not
show that the services at issue are urgent or emergent. 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 hand
therapy services 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 pay for the addition of a tooth to an existing partial denture (D5650) and four additional intraoral periapical x-rays (D0230 x4) provided on September 7, 2021, and September 15, 2021.  You asked the Plan to pay for the addition of a tooth to an existing partial denture and additional intraoral periapical x-rays. You say that you feel you should not be held responsible for these charges. The Plan denied your request. The Plan says the addition of a tooth to an existing partial denture is not a covered expense under your dental plan. The Plan also says that your benefit for the additional intraoral periapical x-rays has been satisfied and the frequency limitation has been exceeded.  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, add tooth to existing partial denture (D5650) not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on September 7, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) and four additional intraoral periapical x-rays (D0230 x4) provided on September 7, 2021, and September 15, 2021.   Your complaint about the negligence of the initial treating provider 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed. 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 service have not been met.
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.