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

We decided that the Plan does not have to pre-approve a Freestyle Libre sensor kit.

You asked the Plan to pre-approve a Freestyle Libre sensor kit. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for continuous glucose monitor 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 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre sensor kit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from April 27, 2021, through May 26, 2021.

You asked the Plan to pay for SNF care. You say that SNF care was medically reasonable and necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 80-year-old female with a cerebrovascular accident with left hemiparesis, dementia and diabetes. In this case, there were no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the enrollee did not require skilled nursing or therapy services on a daily basis. In conclusion, the enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 pay for the skilled nursing facility (SNF) services provided from April 27, 2021, through May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services (J7050) provided on April 22, 2021.
You asked the Plan to pay for code J7050. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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, the CPT Code Manual definition of code J7050 is Infusion, normal saline solution, 250 cc. We find that CPT code J7050 is not supported in the medical record. Specifically, there is no documentation of normal saline solution infusion at 250 cc to support code J7050. Based on this information, we decided that
Medicare rules for coverage of code J7050 have not been met. Therefore, we decided that the Plan does not have to pay for the infusion services (J7050) provided on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Perjeta and Trastuzumab-ANNS for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the information shows enrollment in a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Perjeta and Trastuzumab-ANNS for the enrollee
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle brand test strips.
You asked the Plan to pre-approve Freestyle brand test strips. You say that these requested test strips are medically necessary. The Plan denied your request. The Plan says the requested items are not from a Plan preferred brand.
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 test strips are not a preferred brand with the Plan. The Plan has preferred brands 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. The documentation did not include documentation from your doctor that would specify why the non-preferred brand test strips were medically necessary in your specific situation. Therefore, we decided that the Plan does not have to pre-approve Freestyle brand test strips
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional chiropractic services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the additional skills of a chiropractor are not necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 record indicates that the enrollee has muscle spasms and low back pain. The records provided do not indicate that the additional visits are necessary and would be considered maintenance. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 additional chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown for tooth #20.
You asked the Plan to pre-approve the crown. You say that if you get an infection it could kill you. You say that you had a root canal and need the crown. The Plan denied your request. The Plan says dental services must be completed by a contracted provider.
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 crowns are a covered benefit, dental services are not covered by a non-participating dentist. Contact the Plan regarding receiving the crown from a participating dentist. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #20
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the member has used all of her available 24 one-way trips allowed under her contract.
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 a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.
Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) provided on April 29, 2021.
You asked the Plan to waive the copayment for ambulance transportation. You say that these services should be covered The Plan denied your request. The Plan says the copayment applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for Ambulance services.
You have been asked to pay a $300 copayment for ambulance transportation. 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 ambulance transportation services (A0427) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not 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 assesses 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. Insulin is only taken at bedtime. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that incontinence wipes are medically
necessary. The Plan denied your request. The Plan says incontinence supplies are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this
case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not
have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the requested item. You say that you have one leg and cannot walk. The
Plan denied your request. The Plan says very little clinical information was received about your illness.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We looked at the file and the rules. In this case, there are insufficient medical records to show that you have a
mobility deficit that impairs your participation in MRADLs, that your condition cannot be improved by a
walker, cane or manual wheelchair, or that you can safely operate the PMD being requested. This means that
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to
pre-approve a power wheelchair
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care assistant (T1019) services, 52 units per day.
You asked the Plan to pre-approve the custodial care. You say that you need a personal care assistant because of your health issues. The Plan denied your request. The Plan says personal care assistant services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care assistant (T1019) services, 52 units per day
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires (A4557) provided on March 29, 2021.
You asked the Plan to pay for code A4557. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that code A4557 has a status code of "P" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not have to pay for the lead wires (A4557) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve take-home medication (D9630).
You asked the Plan to pre-approve the dental item. You say that the take-home medication is necessary. The Plan denied your request. The Plan says take home medication is not listed as covered.
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 take-home medication is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve take-home medication (D9630).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 6, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery you had on June 8, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you purchased insurance to help with your medical bills and buying insurance costs you more for these surgeries. You do not think this is fair. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed rate for this service ($254.61) is less than your copayment obligation, you are responsible for the full allowed 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 $290 copayment for outpatient surgery. You have been asked to pay a $290 copayment for the outpatient surgery. 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 outpatient surgery you had on June 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan (93976) and ultrasound (76700) provided on May 14, 2021.
You asked the Plan to pay for codes 93976 and 76700. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. In this case, we have confirmed that code 93976 is a column II code to column I code 76856. Also, code 76700 is a column II code to column I code 93976. 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 duplex scan (93976) and ultrasound (76700) provided on May 14, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for a breast cancer screening provided on June 15, 2021.
You asked the Plan to waive the copayment for a breast cancer screening. You say that you had a name and Plan change and should not be held responsible for the charges. The Plan denied your request. The Plan says that the claims were reprocessed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for breast cancer screenings. The Plan says you must pay a $10 copayment for a breast cancer screening. Based on the Plan contract, however, you cannot be asked to pay for a breast cancer screening. The Plan did not provide any documentation showing that services beyond a breast cancer screening took place, nor that the benefit was exhausted. Furthermore, there is no indication that you did not fit the criteria for a breast cancer screening. Therefore, we decided that the Plan has to waive the copayment for a breast cancer screening provided on June 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) for teeth # 5, 7, 9, 11, and 13.
You asked the Plan to pre-approve the dental services. You say that your denture advised that due to the condition of your bone density, regular dentures will be ill-fitting and may cause long term problems. You also say that the implants are necessary and your only option to secure your loose dentures. The Plan denied your request. The Plan says surgical placement of implant body is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested surgical placement of implant body is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) for teeth # 5, 7, 9, 11, and 13.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone debridement (11044), the muscle and/or fascia debridement (11043, 11046), and the subcutaneous tissue debridement (11042) rendered by the out-of-network (OON) provider on August 11, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the bone debridement (11044), the muscle and/or fascia debridement (11043, 11046), and the subcutaneous tissue debridement (11042) rendered by the out-of-network (OON) provider on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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