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

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve a HFCWOD. You say that the HFCWOD is necessary. The Plan denied your request. The Plan says the HFCWOD is not covered because the enrollee doesn't meet diagnostic criteria.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not have cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency chest wall oscillation device may be covered. The enrollee does not presently use a mechanical in-exsufflation device (E0482) and plans to continue to do so. The records do not show well-documented failure of standard treatments to adequately mobilize retained secretions. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent hospital care services provided on December 28, 2020 to January 14, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the hospital care services. You say that you have rendered treatment to the enrollee in good faith that the service will get reimbursed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 subsequent hospital care services provided on December 28, 2020 to January 14, 2021 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 two surgical extractions (D7210) and to pay more for the mandibular immediate denture (D5140) provided on May 10, 2021.  You asked the Plan to pay for the extractions or pay more for the mandibular immediate denture. You say that you never got the dentures from the previous provider's office. You also say that the last provider was also paid the full dental allowance amount, making it difficult for you to pick up your dentures from the new provider's office. The Plan denied your request. The Plan says the claim reprocessed appropriately up to your $2,000 dental allowance, and you are responsible for the remaining balance of $750.  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 Plan offers a $2,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the May 10, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two surgical extractions (D7210) and to pay more for the mandibular immediate denture (D5140) provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift mechanism.  You asked the Plan to pre-approve a seat lift mechanism. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer says that the item is not medically necessary. Our physician reviewer found the record does not indicate that part of the treating practitioner's course of treatment and be prescribed to improve, or stop deterioration of, your condition. The record provided does not establish that the coverage criteria of the requested service are satisfied. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve microprocessor knee for C-leg prosthesis (L5828, L5845, L5848, L5856).  You asked the Plan to pre-approve microprocessor knee for C-leg prosthesis. You say that the enrollee is a K3 ambulator, so the C-leg with microprocessor is necessary. The Plan denied your request. The Plan says the Plan will grant the K3 leg prothesis, but the documentation does not indicate the need for the microprocessor knee, particularly if the mechanical knee if more durable for the enrollee's preferred activities.  The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. The documentation does not show why microprocessor knee is medically necessary or why mechanical knee will not meet member's needs.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of microprocessor knee for C-leg prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve microprocessor knee for C-leg prosthesis (L5828, L5845, L5848, L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a preventive medicine evaluation visit provided on April 12, 2019 by an out-of-network (OON) provider.  You asked the Plan to pay for office visit. You say that you were told this bill would be paid. 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 a preventive medicine evaluation visit provided on April 12, 2019 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on March 26, 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 testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met. 

We looked at the file and Medicare rules. The file shows that there is no documented prior biopsy results. 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 pay for the ConfirmMDx testing rendered on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mattress replacement to be provided by an nonparticipating provider.

You asked the Plan to pre-approve the mattress replacement. You say that you require the replacement mattress for your bed. The Plan denied your request. The Plan says based on the additional information available, the request does not meet the Medicare or Plan's coverage criteria.

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. Craftmatic is also not a Medicare certified vendor and their beds and mattresses are considered furniture, not durable medical equipment, therefore not covered.

The requested provider in this case is not a network provider with the Plan. 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 mattress replacement to be provided by an nonparticipating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 28, 2021.  You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you cannot afford to pay for these services at this time. The Plan denied your request. The Plan says your dental maximum has been met.  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 Plan offers an annual maximum dental allowance of $1,000. The record shows that you met the annual maximum benefit on February 11, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 28, 2021.   Your complaint about being misinformed about the Plan's coverage when speaking with the Plan's sales representative 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that the patient meets the medical management criteria and need for physician oversight. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.  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. At the current medical stability and lack of other medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute nursing care needs. Based upon the enrollee's current level of function, he does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee will not make a significant functional progress in 7-10 days in an IRF, and his rehab needs can be safely met in a low intensity setting of a skilled nursing facility (SNF). Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 you need a higher level of rehabilitation than a skilled nursing facility. You say that IRF care is needed for your quality of life and to regain a higher level of self-care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care needed in another setting.  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 at the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation (PMR) physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute nursing care needs. Based upon the enrollee's current level of function, he does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee needs physical therapy and occupational therapy in an alternate and low intensity level. While the enrollee may benefit from physical therapy and occupational therapy, his rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF) or in-home with therapies.  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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from June 16, 2021, through  July 15, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says SNF services are not medically necessary.  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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF from June 16, 2021, through July 15, 2021. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF level need. The enrollee's functional level did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF during the dates in question. The enrollee did not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF from  June 16, 2021, through July 15, 2021.  As a practical matter, this enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facility setting from June 16, 2021, through July 15, 202  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from June 16, 2021, through July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from June 14, 2021, to July 7, 2021.  You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient admission was medically necessary, clinically appropriate, and consistent with the best local and national standards of care. The Plan denied your request. The Plan says that there is no authorization for these dates of service.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on June 14, 2021 with altered mental status. The enrollee was evaluated with a physical exam, laboratory studies and imaging. He had an open abdominal wound with subcutaneous tracts visualized on a computed tomography scan. Our reviewer found that the enrollee was started on intravenous antibiotics and admitted. He was evaluated by Nephrology and Infectious disease. He required ventilator support and received continued intravenous antibiotics. The enrollee also received total parenteral nutrition. Despite maximal treatment he became hypotensive requiring fluids and vasopressor support. He was evaluated by Gastroenterology and General Surgery. The enrollee continued to deteriorate and expired on July 7, 2021. Our physician reviewer also found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.     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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 14, 2021, to July 7, 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 June 18, 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 are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services you received on
July 23, 2021.

You asked the Plan to waive the copayment for the physical therapy services. You say that you did not receive
physical therapy services on this date because you were out of town. The Plan denied your request. The Plan
says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment per visit for physical therapy services.

You have been asked to pay a $40 copayment per visit for the physical therapy services. We looked at the
medical records to show if you received services on this date. The records show that you were at the physical
therapy facility at Linden Oaks on July 23, 2021, and received manual therapy during this visit. 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 physical therapy services you received on July 23, 2021.