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

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered when specific criteria 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 home ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume assured pressure support (AVAPS) capability. The plan has indicated such a device is available for coverage if requested. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services you received
from an out-of-network dermatologist on June 23, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were never
advised that this was an out-of-network provider and you should have been referred to an in-network provider.
The Plan denied your request. The Plan says you received radiation therapy (i.e., therapeutic radiological
procedures) on this date of service. You were assessed the correct coinsurance for this service. Although this
provider is out-of-network, these services were assessed the in-network 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 20%
coinsurance for therapeutic radiology services.
You have been asked to pay 20% coinsurance for the radiation therapy services. The radiation therapy services fall within the therapeutic radiology 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 coinsurance for radiation therapy services you received from an out-of-network dermatologist on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 treatment. Our reviewer says that the services are medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does meet the criteria for October 18, 2021 forward as although this enrollee was not shown to be a danger to herself or others, she was showing auditory no visual hallucinations and was not cooperative/compliant with treatment. 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 treatment have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric treatment.
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 pre-approve an office visit (99204) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that this care from an OON provider is medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide this 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 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 an office visit (99204) to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometrist services provided to the enrollee on September 15, 2021.

You asked the Plan to pay for the services. You say that you do not agree with this denial. 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 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 optometrist services provided to the enrollee on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a participating provider on September 13, 2021.
You asked the Plan to pay for a maxillary partial denture. You say that your upper partial denture was stolen out of your gym bag. You say that you needed new ones so you could eat. The Plan denied your request. The Plan says the dental allowance for a partial denture has already been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maxillary partial denture once every five years. We looked at this the file and Medicare rules. Evidence was provided to show that a partial maxillary denture was provided on May 23, 2018.
Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture have not been met. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a participating provider on September 13, 2021.
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 IRF care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that on review of the available records the enrollee with lumbar spinal stenosis does not meet Medicare coverage criteria for an IRF admission.
With your current medical stability, and no 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. At the current functional level, you do 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. While you may benefit from continued physical and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or in-home with therapy services. 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 pay for a continuous glucose monitor (K0553) provided to the enrollee on July 10, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation shows that the enrollee was not interested in obtaining this monitor at the time the order was written.
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 Healthcare Common Procedure Coding System (HCPCS) code K0553 is "Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service." We find that CPT code K0553 is not supported in the medical record. Specifically, the order for this case is not valid, as the documentation shows that the enrollee was not interested in obtaining the monitor when the order was written. 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 pay for a continuous glucose monitor (K0553) provided to the enrollee on July 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services for utilization of controlled hypotension provided during a procedure on June 11, 2021, billed with code 99135.
You asked the Plan to pay for the special anesthesia services. You say that this claim should be paid. The Plan denied your request. The Plan says additional codes were approved for payment; however, 99135 is 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.
Code 99135 has a status indicator of "B" on the Physician Fee Schedule. This means that payment is bundled with other services provided. Based on this information, we decided that Medicare rules for coverage of the special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services for utilization of controlled hypotension provided during a procedure on June 11, 2021, billed with code 99135.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapy and should be independent with a home exercise program. Our reviewer says that the additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are not medically 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 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three (3) crowns for tooth #5, #6 and #7 (D2751) and a core buildup, including any pins when required (D2950) provided on August 31, 2021.
You asked the Plan to pay for 3 crowns and a core build-up. You say that you disagree with the denial and would like for the Plan to reconsider payment. The Plan denied your request. The Plan says a core build-up is not a listed benefit and is therefore not covered. The Plan also says you received a crown on tooth #8 and 9, therefore, exhausting your benefit for a crown.
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.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of 3 crowns and a core build-up have not been met. The EOC confirms that a core build-up is not a covered benefit with your Plan. The records show you received a crown for tooth #8 and #9 on August 31, 2021. The EOC also confirms that you receive 2 crowns once, per calendar year. Specifically, you have exhausted your crown benefit with your Plan. Therefore, we decided that the Plan does not have to pay for three (3) crowns for tooth #5, #6 and #7 (D2751) and a core buildup, including any pins when required (D2950) provided on August 31, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for the anterior instrumentation (22845-59). We decided that the Plan does not have to pay for the bone marrow grafting (20930).
You asked the Plan to pay for the anterior instrumentation (22845-59). You say that this should be paid as billed. The Plan says that it was decided that no decision is required for code 22845. In addition, code 20930 is not separately payable.
We decided that the Plan has to pay for the anterior instrumentation (22845-59).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has neglected to provide a denial rationale to support non-payment of this code. Without a valid rationale, we are not able to determine whether the Plan's denial is supported. Therefore, we decided that the Plan has to pay for the anterior instrumentation (22845-59).
We also decided that the Plan does not have to pay for the bone marrow grafting (20930).
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code 20930 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this code is always bundled in payment for other services. Therefore, we decided that the Plan does not have to pay for the bone marrow grafting (20930).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric Hoyer lift for the enrollee.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your
request. The Plan says this is medically necessary.
The Plan must follow Medicare rules. The rules say that a patient lift is covered if transfer between bed and a
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined.
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 lift. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation supports that the enrollee requires a mechanical lift for transfers. Her caregivers
require a mechanical lift for transferring her in a safe manner and the health plan has authorized a standard
hydraulic lift. There is no documentation that an electric lift is required to transfer the enrollee.
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 lift have not been met. Therefore, we decided that the Plan does not have to
pre-approve an electric Hoyer lift for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy (PT) visits (97110) provided on June 3, 2021, to July 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to waive the copayment for PT visits. You say that these providers should be processed as in-network because the practice is in-network with the Plan. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $55 copayment for each Medicare-covered physical therapy visit with an out-of-network provider.
You have been asked to pay a $55 copayment for each PT visit. The records show you had 6 PT visits with your provider. The EOC confirms that you pay a $55 copayment for each visit. Your total cost share is $330 ($55 x 6 visits = $330). PT visits fall within the outpatient rehabilitation 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 physical therapy (PT) visits (97110) provided on June 3, 2021, to 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 sacral joint surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is lack of prior treatment history to support the need for this surgery.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for sacroiliac joint fusion is not met. More conservative measures for back pain are needed. This surgery for back pain remains experimental and controversial without cases of instability. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral joint surgery for the enrollee.
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 should only require short-term additional acute care that can be completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick.
You asked the Plan to pre-approve Repatha. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha SureClick.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.