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

We decided that the Plan does not have to pay for gingival irrigation (D4921).

You asked the Plan to pay for the services. You say that you had the same cleaning three months prior, and it was fully covered. The Plan denied your request. The Plan says this 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 pay for gingival irrigation (D4921).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your condition has improved, and you are no longer a threat.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from October 11, 2021, were requested. 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 it was not expected you would improve in a reasonable period of time beyond the date in question. You did not have dangerousness to self or others, but you were compliant with your treatment.
It did not appear that the services were for the purpose of diagnosis. You did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You did not show any abnormal behaviors or any symptoms which would require acute 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a PET (positron emission tomography)
scan provided on March 30, 2021.
You asked the Plan to reduce the copayment for a PET scan. You say that your cost sharing is too high in
comparison to the test you had last year. You say you would like the Plan to reduce your amount to less than
$400 to be in proportion to other claims. The Plan denied your request. The Plan says you have been asked to
pay 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 20%
coinsurance for diagnostic radiology services, including PET scans.
You have been asked to pay $1,598.08, which is 20% of the allowed amount for the scan ($7,990.40 allowed
amount x 20% coinsurance = $1,598.08). A PET scan falls 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 reduce the copayment for a
PET (positron emission tomography) scan provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided in the current acute care setting.
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. You were admitted with acute hypoxic respiratory failure. You continue to have oxygen desaturations and is not responding to steroid therapy. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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 pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you ask for reconsideration and approve coverage so that the enrollee may continue to receive this medically necessary treatment. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3260).
You asked the Plan to pre-approve foot orthotics. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records do not show that you suffer from diabetic foot disease or that you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 23, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 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 out of network physician services provided to the enrollee on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says there are providers in network who can render treatment.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9945).
You asked the Plan to pre-approve the dental item. You say that you need a night guard for grinding your teeth. You say that your mouth is a different shape. You also say that you need it custom made from the dentist. The Plan denied your request. The Plan says occlusal guard is not listed as a covered dental item. The Plan also says that occlusal guard is not covered by Medicare.
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 occlusal guard is not among those covered under this benefit. Additionally, the item you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session (G6015). You say that treatment with IMRT is necessary. The Plan denied your request. The Plan says Original Medicare is responsible for covered clinical trial services.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The enrollee is in a Medicare approved clinical research study
therefore Original Medicare covers the cost of routine care associated with the clinical trial. Based on this
information, we decided that Medicare rules for coverage of intensity modulated treatment delivery, single or
multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment
session (G6015) have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity
modulated radiation therapy (IMRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute and does not require transfer to the LTACH.
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 necessitating 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 he 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was
admitted to the hospital on September 21, 2021, with generalized weakness, low grade fever, and hypoxia. The
hospital course was complicated by cardiac arrest requiring temporary cardiac pacing and progressive
respiratory failure requiring tracheostomy. There is no documentation provided necessitating 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 he/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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee would greatly benefit from the intensive therapy and monitoring of a rehabilitation setting. The Plan denied your request. The Plan says IRF level of care is not medically necessary.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued stay at the skilled nursing facility (SNF)
provided from March 25, 2021, to April 23, 2021.
You asked the Plan to pay for the continued stay. You say that the services are coverable under the Medicare
Act. The Plan denied your request. The Plan says the enrollee did not receive any daily skilled services on the
dates of service in this case. The Plan says custodial care is when you need assistance with routine daily
activities. The Plan also says custodial care is 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 continued stay 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 pay for the continued stay
at the skilled nursing facility (SNF) provided from March 25, 2021, to April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repair of penile prosthesis (54408).
You asked the Plan to pre-approve the repair of penile prosthesis. You say that this should be considered medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. We looked at the file and Medicare rules. In this case, this request does not appear to be necessary for the diagnosis or treatment of an illness or injury. Instead, the procedure appears to be cosmetic in nature. Based on this information, we decided that Medicare rules for coverage of the repair of penile prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve the repair of penile prosthesis (54408).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre. You say that the enrollee has lost the dexterity to perform the required number of blood sugar checks and needs the Freestyle Libre. The Plan denied your request. The Plan says rules for continuous glucose monitors 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 available documentation does not indicate that the enrollee uses insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 and the insertion
or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter coded 33210
provided on January 6, 2021 to January 14, 2021.
You asked the Plan to pay for the moderate sedation services and the insertion or replacement of temporary
transvenous single chamber cardiac electrode or pacemaker catheter. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
Medicare rules say that providers must report services correctly. Providers must report services with the
appropriate CPT code.
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 33210
for the moderate sedation services and the insertion or replacement of temporary transvenous single chamber
cardiac electrode or pacemaker catheter has a bundled relationship with code 93454 and cannot be paid as
billed. This code cannot be paid as a separate line item. We find that CPT 99153 is not supported in the medical
record. Specifically, this code has a professional component (PC)/technical component (TC) indicator of 3.
This means this code is not payable as billed. Based on this information, we decided that Medicare rules for
coverage of the moderate sedation services have not been met.
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 moderate sedation services coded 99153 and the insertion or replacement of
temporary transvenous single chamber cardiac electrode or pacemaker catheter coded 33210 provided on
January 6, 2021 to January 14, 2021.