Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the heart rendered on May 27, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that services while inpatient must be billed with Place of Service (POS) code 21. 

We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue and the claim was incorrectly billed with POS code 22 for outpatient. 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 computed tomography angiography (CTA) of the heart rendered on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.

You asked the Plan to pre-approve Tadalafil. You say that the enrollee has been on this medication for years. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 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 Tadalafil.

Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has flat feet, deformities, and
arthritis in her feet. 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 show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot
orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relistor.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Relistor.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy procedure you had with a specialist on March 17, 2021.

You asked the Plan to waive the copayment for the endoscopy procedure. You say that this should be covered in full The Plan denied your request. The Plan says it initially processed this claim as an outpatient hospital surgery with a cost sharing of $350. The Plan has fixed the error and reprocessed your claim, leaving a copayment of $45. The Plans says this $45 copayment was charged 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 $45 copayment for services rendered by a physician specialist.

You have been asked to pay a $45 copayment for the endoscopy procedure. The endoscopy procedure falls within the services rendered by a physician specialist 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 the endoscopy procedure you had with a specialist on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the functional brain mapping (96020) provided on February 8, 2021, through March 3, 2021.

You asked the Plan to pay for the functional brain mapping. You say that you would like reconsideration because you found this provider through a support group and look forward to reimbursement. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.

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 pay for the functional brain mapping (96020) provided on February 8, 2021, through March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.
You asked the Plan to pre-approve a bath/shower chair. You say that the records provided support that the
requested item is medically necessary. The Plan denied your request. The Plan says shower and bath chairs are
not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair 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 a bath/shower chair
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
You asked the Plan to pre-approve 5 additional home health physical therapy visits. You say that these services continue to be medically necessary. The Plan denied your request. The Plan says home physical therapy visits are not medically necessary in this case.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 5 additional home health physical therapy visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented home skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on January 28, 2021.
You asked the Plan to pay for the services provided. You say that benefits were significantly reduced. The Plan denied your request. The Plan says Medicare cannot reimburse a surgical assistant's services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.
We looked at the file and the rules. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on January 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of-network (OON) provider from April 12, 2021, through May 17, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of-network (OON) provider from April 12, 2021, through May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 23 additional routine transportation trips.
You asked the Plan to provide additional routine transportation. You say that this additional transportation is necessary for the enrollee to get to their medical appointments. The Plan denied your request. The Plan says the routine transportation benefit covers 48 trips per calendar year. Additional trips are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 23 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 prosthesis.

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 provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are
furnished by a provider or supplier enrolled in the Medicare program.

We looked at the file and Medicare rules. The file shows that the provider is not Medicare-certified. 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 a MyoPro 2 prosthesis.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for the arthrodesis services coded as 22586-AS. We decided that the Plan does not have to pay for the autograft/allograft coded as 20936-AS and 20930-AS.
You asked the Plan to pay for the arthrodesis services coded as 22586-AS. You say that these services should be paid as they were medically necessary and pre-approved. The Plan says that it was decided to make payment for codes 63047 and 22840, but the other two codes are not separately payable.
We decided that the Plan has to pay for the arthrodesis services coded as 22586-AS.
Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). In this case, the Plan did not forward any information to support the denial of this code. The claim was denied stating that the services is considered experimental; however, the file included an authorization from the Plan specifically for this code. The Plan cannot authorize a code then retroactively decide that the service is experimental. Without a valid denial rationale and the authorization for this code, we find that the denial is not supported. Therefore, we decided that the Plan has to pay for the arthrodesis services coded as 22586-AS.
We also decided that the Plan does not have to pay for the autograft/allograft coded as 20936-AS and 20930-AS.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed.
CPT codes 20936 and 20930 have a status indicator of "B" in the Physician Fee Schedule. This means that payment for these services is bundled in payment for other services. No separate payment can be made for these codes. Therefore, we decided that the Plan does not have to pay for the autograft/allograft coded as 20936-AS and 20930-AS.
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 pay for the office visit (99205) rendered by the out-of-network (OON) provider on April 27, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without a prior referral from your primary care physician.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99205) rendered by the out-of-network (OON) provider on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for hearing aids.
You asked the Plan to pre-approve hearing aids. You say that you have a severe medical condition that is requiring you to use hearing aids. The Plan denied your request. The Plan says hearing aids are excluded from your Plan benefits.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that hearing aids and tests to determine their efficacy, and hearing tests to determine an appropriate hearing aid are excluded from coverage. We looked at this physician's review, the file, and the Plan's rules. The services at issue are not covered benefits of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve coverage for hearing aids.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on April 13, 2021.
You asked the Plan to pay for the emergency room services. You say that this claim should be reprocessed for payment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $90 copayment for emergency care services.
You have been asked to pay a $90 copayment for the emergency room services. This service falls within the emergency care 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 pay for the emergency room services provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on May 17, 2021.
You asked the Plan to pay for the bone replacement graft. You say that this service was necessary. The Plan denied your request. The Plan says this service is not covered by your dental 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 the bone replacement graft for ridge preservation (D7953) provided on May 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are receiving adequate and necessary services in the inpatient rehabilitation facility.
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 services. Our physician reviewer found that you were found to have a stroke and were admitted to an inpatient rehabilitation facility. You do not require the skilled nursing services of a professional nurse to provide treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF needs. Your functional level does not require the skilled therapy services of a qualified therapist to provide medically necessary treatment in a SNF. You do not require skilled nursing or skilled therapy services on a daily basis in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.

You asked the Plan to pre-approve Gel-One. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there has not been 3 months of conservative therapy tried.

The Plan must follow Medicare rules. Medicare rules say that you must have failed at least three months of conservative therapy for viscosupplementation therapy to be 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 Gel-One. Our reviewer says that Gel-One is not considered medically reasonable and necessary in this case. Your injury was on August 10, 2021. This request was submitted on a September 27, 2021 evaluation. There was no detailed indication of recent, comprehensive and reasonable conservative treatment provided for the injury. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines. Our physician reviewer found that your condition does not meet Medicare criteria for Gel-One. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve these services. You say that the oxygen tank provided by the Plan interferes
with your work and activities. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a portable oxygen concentrator.