Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant (D6010), and a custom fabricated abutment (D6057 and D6059) to be provided by a participating provider.

You asked the Plan to pre-approve an endosteal implant and a custom fabricated abutment. You say that this dental work is medically necessary. The Plan denied your request. The Plan says the requested dental work is not a covered benefit.

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 an endosteal implant (D6010), and a custom fabricated abutment (D6057 and D6059) to be provided by a participating provider.
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 an LTACH is the most appropriate level of care, as the enrollee has had multiple complications during this hospitalization. You say that you would like to prevent readmission to the short-term acute care hospital. The Plan denied your request. The Plan says LTACH care is not medically necessary. The Plan says that a continued stay at an acute hospital until the enrollee is stable enough for discharge to a lower level of care has not been denied.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that there have been two radiofrequency sessions in the prior twelve months.

The Plan must follow Medicare rules. The rules say that for each covered spinal region, no more than two radiofrequency sessions will be reimbursed per rolling twelve months. 

The file shows that radiofrequency procedures were rendered on January 28, 2021 and March 4, 2021. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says inpatient psychiatric care is not medically necessary. The Plan says that the enrollee could be treated at a lower level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.     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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on February 11, 2022, with Unspecified Psychosis Not Due To Substance or Known Physiologic Condition. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider.
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. You
say that you are in need of special contact lenses and if you are not seen by this doctor, your eye condition can
worsen, and you could possibly lose your eyesight. The Plan denied your request. The Plan says you must use
network providers to get medical care and services when there are network providers available. The only
exceptions are emergencies and urgently needed services when the network is not available
(generally, when you are out of the area) and out-of-area dialysis services. You should always confirm
authorization requirements before receiving services. Based on the medical records received it was determined
that this is not an emergency and there are providers within your health Plan network for a consultation with
an optometrist
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office
visit to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is no documentation why the enrollee is not a candidate for radiofrequency ablation.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has a history of chronic lower back pain due to lumbar spondylosis and radicular pain in both lower extremities. She has been treated with medications, physical therapy, rest, ice, and heat. She had a radiofrequency ablation of the L4 and L5 levels in June 2020, with 95% improvement. She also had medical branch blocks in January 2021, of L4 and L5 with 90% improvement. In this case, the medical record does not include radiographic studies supporting the absence of untreated radicular pain (noted in the medical history) or absence of non-facet pathology. In addition, there is no documentation as to why she is not a candidate for radiofrequency ablation, given good responses in the past. Therefore, the requested treatment 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says that the Plan does not cover out-of-network services rendered with the exceptions of the following: Emergency care or urgently needed services that you get from an out-of-network provider. This includes worldwide coverage if covered by your Plan. If you need medical care that Medicare requires our Plan to cover and providers in our network cannot provide this care, you can get this care from an out-of-network provider. For these types of referrals, you must obtain authorization before seeking care.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on September 20, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that the provider informed you that it was a routine exam. 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 $40 copayment for exams to diagnose and treat diseases of the eye. 

The records show that this was an initial exam for new patients, involving diagnostic tests for different conditions. Therefore, you have been asked to pay a $40 copayment for the eye exam.

The eye exam falls within the Vision Care 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 a diagnostic eye exam provided on September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator from an out-of-network
provider.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from network providers.

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 portable oxygen concentrator from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after
February 11, 2022.
You asked the Plan to pre-approve SNF care. You say that you cannot walk or feed yourself. The Plan denied
your request. The Plan says your needs are custodial.
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 the records do not show that you have skilled
nursing or therapy needs. Services 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 continued skilled nursing facility (SNF) care after February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
You asked the Plan to pre-approve these services. You say that additional sensors are needed. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that more than one unit of service per 30 days of
CGM supplies is denied as not medically necessary.
We looked at the file and Medicare rules. The file shows that the requested services are CGM supplies beyond
the approved one unit of service per 30 days. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve
continuous glucose monitor (CGM) supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483, 80307) provided February 10, 2021.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the records 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 find that CPT code G0483, & 80307 is not supported in the medical record. Specifically, the place of service on the claim form does not match the place of service detailed in the records. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483, 80307) provided February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010), abutment supported porcelain fused to metal crown (high noble metal) (D6059) and custom fabricated abutment - includes placement (D6057).
You asked the Plan to pre-approve an endosteal implant, abutment supported crown and custom fabricated abutment. You say that these dental services are medically necessary. The Plan denied your request. The Plan says these services are 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 surgical placement of implant body: endosteal implant (D6010), abutment supported porcelain fused to metal crown (high noble metal) (D6059) and custom fabricated abutment - includes placement (D6057).
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve Zio Patch cardiac event monitoring.  You asked the Plan to pre-approve Zio Patch cardiac event monitoring. You say that the requested Zio Patch cardiac event monitoring is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested Zio Patch cardiac event monitoring. 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 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 Zio Patch cardiac event monitoring. Our reviewer says that the enrollee meets criteria for the requested Zio Patch cardiac event monitoring. Our physician reviewer found while a mobile cardiac outpatient telemetry (MCOT) monitor would not be appropriate, an ambulatory ECG monitor of 1 day to 2 weeks duration is reasonable to allow assessment of rate control of the arrhythmia during day-to-day activities. As a result, use of an ambulatory ECG monitor, but not an MCOT monitor, would be considered medically appropriate and necessary in this enrollee's clinical management. The enrollee meets criteria for the requested Zio Patch cardiac event monitoring.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zio Patch cardiac event monitoring have been met. Therefore, we decided that the Plan has to pre-approve Zio Patch cardiac event monitoring.   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 waive the copayment for laboratory services provided on  October 12, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that the service should be part of your annual physical. 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 $10 copayment per day for laboratory tests that are not FIT tests.   We looked at the file. There is no evidence in the EOC that shows that laboratory services for an annual physical are not charged. Therefore, you have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided June 8, 2021
You asked the Plan to pay for lab services. You say that the lab services were 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 that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided June 8, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Motivo upright walker.
You asked the Plan to pre-approve a Motivo upright walker. You say that the requested item is a necessity for your care. 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, for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Motivo upright walker have not been met. Specifically, the item at issue is not a covered benefit. The manufacturer website (buymotivo.com) states that the item at issue in this case is not coded for Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a Motivo upright walker.