Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve remote physiological monitoring services coded as 99453, 99454, 99457 and 99458.
You asked the Plan to pre-approve remote physiological monitoring services. You say that these code set comes under remote physiological monitoring and as per CMS guidelines, CPT codes 99453, 99454, 99457 and 99458 are covered for the year 2021 under RPM rules of CMS. The Plan denied your request. The Plan says that the provider has not shown that his office has the capability of collection of the remote data. The provider has not shown that the enrollee can collect and submit this information to the office.
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 not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has not substantiated their denial. There is no evidence in the file that the provider is not capable of collecting remote data or that the member is not able to submit the data. Additionally, CPT codes 99457 and 99458 require 2-way audio with the capability of being enhanced with video or other kinds of data transmission. There is no evidence that the provider does not intend to or is incapable of rendering this service. Therefore, we decided that the Plan has to pre-approve remote physiological monitoring services coded as 99453, 99454, 99457 and 99458.
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 a heel lift.
You asked the Plan to pre-approve a heel lift. You say that a heel lift is necessary as one leg is shorter than the other due to surgery. 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. The records show that you do not suffer from diabetic foot disease and you do not 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 a heel lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are unable to care for yourself and need placement before you can be discharged. The Plan denied your request. The Plan says that the records received show your condition has improved and you are no longer a threat to yourself or others.

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 hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant and cooperative with treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the below knee, flexible protective outer surface covering system (L5962)
You asked the Plan to pre-approve the outer surface covering system. You say that you are requesting reconsideration for both codes: L5987 and L5962. The Plan denied your request. The Plan says the notes do not show why approved L5704 is not sufficient to meet enrollee's needs.
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 outer surface covering system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not exposed to a harsh wet environment to meet for the requested extra protective cover. The review has determined that the items/services at issue in this case are not medically reasonable or necessary and do not meet the criteria for Medicare coverage. 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 outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve the below knee, flexible protective outer surface covering system (L5962
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on May 28, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that the appropriate DEX Z-Code identifier adjacent to the CPT code must be billed in the comment/narrative field. We looked at the file and Medicare rules. The file shows that the services were not billed with the required DEX Z-Code. 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 GeneSight Psychotropic Assay rendered on May 28, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on May 27, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you met the MOOP amount for 2020 and should not be responsible for 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 the MOOP amount for 2020 is $2,800. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on May 27, 202. The record shows that you had only paid $2,520 toward the $2,800 MOOP amount. Therefore, you are responsible to pay $245, which is less than the 20% coinsurance amount. You have been asked to pay $245 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay (L3216).

You asked the Plan to pre-approve foot orthotics. You say that you had a stroke and needs the shoe to help align your body properly to walk and prevent you from having drop foot, foot pain and help your curled toes. 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. 

The Medicare Local Coverage Article A52481 specifically lists L3216 as a non-covered item. 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 orthopedic footwear, ladies shoe, depth inlay (L3216).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 27, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on April 27, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are ready to transition to the next level of care, you are unsteady, and you have no support system. The Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting. The Plan states the services you require are called custodial care. The Plan states custodial care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the bathroom, and eating. The Plan states custodial care is not a covered benefit under Medicare or the health plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the limited documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair van for non-emergent transportation.
You asked the Plan to pre-approve the wheelchair van for non-emergent transportation. You say that you need to be transported to a Methadone clinic for visits as your health requires it. The Plan denied your request. The Plan says your provider does not have any clinical information to support the need for a wheelchair van for non-emergent transportation.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. There is no documentation from a provider that you are unable to ambulate with or without assistance; OR are unable to ambulate with or without an assistive device; OR that you require assistance getting into, or out of, a vehicle. Therefore, we decided that the Plan does not have to pre-approve wheelchair van for non-emergent transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapy services provided by a chiropractor.
You asked the Plan to pre-approve outpatient therapy services. You say that he exacerbated his injuries, and you are asking for more visits. You say that massage therapy as well as other therapies would greatly benefit this patient. The Plan denied your request. The Plan says Medicare does not cover physical therapy by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve outpatient therapy services provided by a chiropractor
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the application of desensitizing resin.

You asked the Plan to pre-approve the application of desensitizing resin. You say that you are upset that you aren't able to get a simple cavity filled when your plan covers two fillings per year. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the application of desensitizing resin.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting, or that you did when you were admitted on December 2, 2021. The Plan states your records say you will be a long-term care resident of the facility, your medical issues appear essentially stabilized, and you were planning to receive episodic outpatient, Part B therapy. The Plan states the services you required are called custodial care. The Plan states custodial care helps you with daily needs such as dressing, bathing,
getting in and out of bed, going to the bathroom, and eating. The Plan states custodial care is not a covered benefit under Medicare or the health plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the limited documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved and you are no longer a threat to yourself or others.

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 hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others and were compliant with your treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power mobility device replacement (CPT code E1399), for the enrollee.
You asked the Plan to pre-approve the item. You say that the enrollee is unable to perform daily task without the power wheelchair. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records do not provide that required information such as a detailed written order (DWO), home evaluation, product information and the enrollee's cognitive ability status.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the item have not been met. The limited record sent by the enrollee's provider does not contain a DWO, home evaluation or confirmation that the enrollee has the ability to operate a new power mobility devise and there is no information regarding the age or condition of the enrollee's current device including information regarding possible repair. Therefore, we decided that the Plan does not have to pre-approve power mobility device replacement (CPT code E1399), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs.
You asked the Plan to pre-approve these services. You say that you are paraplegic and need your wheelchair for mobility. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a functioning manual wheelchair. You are requesting repairs to a back-up wheelchair, which serves the same purpose as the functioning wheelchair. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the repairs are not covered.

The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for repairs exceeding the cost of the equipment. 

We looked at the file and Medicare rules. The file shows that the requested repairs exceed the cost of the equipment. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whirlpool bathtub.
You asked the Plan to pre-approve whirlpool bathtub. You say that a whirlpool bathtub is medically necessary. The Plan denied your request. The Plan says a whirlpool bathtub is not covered by Medicare and you do not meet the criteria for an inserted whirlpool tub attachment.
The Plan must follow Medicare rules. Medicare rules say that shower and bath equipment is not covered because they are not primarily medical in nature. Medicare rules say a whirlpool tub insert, which is a rented attachment inserted to your current bathtub, is covered if you cannot receive relief from a traditional warm bath and you cannot leave your home. The records do not show that you meet either of these criteria. While a whirlpool tub may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve whirlpool bathtub