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

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this item is 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 shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical additional radiographic image (x-ray) (D0230), provided on April 23, 2021.
You asked the Plan to pay for the periapical additional x-rays. You say that the services should be covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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. Specifically, you have exceeded the Plan's frequency limitation for this service. Therefore, we decided that the Plan does not have to pay for the periapical additional radiographic image (x-ray) (D0230), provided on April 23, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says that this drug is not approved for repeat use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Zilretta. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knee. Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. Based on the drug label, it does not preclude use of the drug more than one time. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Zilretta have not been met. Therefore, we decided that the Plan has to pre-approve Zilretta.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a urine polymerase chain reaction test (PCR) panel provided to the enrollee on February 17, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this testing is considered unproven and not medically necessary. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The review has determined that the enrollee does not meet the criteria for this testing. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for a urine polymerase chain reaction test (PCR) panel provided to the enrollee on February 17, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Zilretta injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not show an inadequate response to previous treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 injection. Our reviewer says that the 
requested injection is medically reasonable and necessary. Our physician reviewer found per the Food and 
Drug Administration (FDA) approved prescribing information, Zilretta is indicated for the management of knee 
pain due to osteoarthritis.  Based on a review of the information submitted, the enrollee has not yet received a 
Zilretta injection for the right knee. The documentation supports that Zilretta is medically reasonable and 
necessary for the enrollee, and is safe and effective for 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve a Zilretta injection for the enrollee.  
 
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 moderate sedation services provided on March 11, 2021.
You asked the Plan to pay for the services provided. You say that the claim was billed using the correct place of service. The Plan denied your request. The Plan says the service was not billed as required by guidelines.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.
We looked at the file and the rules. In this case, the service at issue was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placements, custom fabricated 
abutments and abutment supported crowns. 
 
You asked the Plan to pre-approve the surgical implant placements, custom fabricated abutments and abutment 
supported crowns. You say that you want to appeal the denial. The Plan denied your request. The Plan says the 
services are not medically necessary. 

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 the surgical 
implant placements, custom fabricated abutments and abutment supported crowns when the services are 
medically necessary and reasonable.  
 
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 surgical implant placements, custom 
fabricated abutments and abutment supported crowns. Our reviewer says that the requested services are not 
medically necessary. Our physician reviewer found that there are three requested implants for the upper arch, 
exceeding the requirement of a single missing tooth to qualify for an implant and the implants are not intended 
to support a full denture. Our reviewer says that although implants are an option, it is not the only treatment 
option, and not covered under the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical implant placements, custom fabricated abutments and abutment 
supported crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
surgical implant placements, custom fabricated abutments and abutment supported crowns.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a continued stay at a skilled nursing facility (SNF) provided from April 19, 2021, to May 18, 2021.

You asked the Plan to pay for the continued SNF stay. You say that the continued stay is medically necessary. The Plan denied your request. The Plan says the enrollee did not require daily skilled services on the dates of service in this case.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the continued SNF stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the continued SNF stay have not been met. Specifically, the file shows that the enrollee did not require daily skilled services on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for a continued stay at a skilled nursing facility (SNF) provided from April 19, 2021, to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (S9999, 00731) provided on March 30, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were necessary for the 
procedure performed and should be covered. The Plan denied your request. The Plan says the services were 
provided out-of-network and are not covered. 
 
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 services 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 
these services. No medical records were provided to show that the services were emergent in nature. Therefore, 
we decided that the Plan does not have to pay for anesthesia services (S9999, 00731) provided on March 30, 
2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a LAAC and Watchman procedure (33340).
You asked the Plan to pre-approve a LAAC and Watchman procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says that conservative measures (anticoagulant medications) have not been failed.
The Plan follows Medicare rules. Medicare rules say that a LAAC procedure will be covered if the criteria in the Medicare rules section of this letter have been 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 LAAC and Watchman procedure. Our reviewer says that the requested service is a medical necessity in this case. Our physician reviewer found that the enrollee has an elevated CHA2DS2-VASc score (6) and requires long term anti-coagulation. The enrollee is at a moderate risk for long-term anticoagulation therapy. In addition, there is documentation in the form of letter that the enrollee's primary care physician (independent, non-implanting physician) performed an evaluation and using shared decision making and based on the enrollee's age and prior anemia history determined the suitability for Watchman therapy in lieu of long-term anti-coagulation in this situation. The performing center also specifies they have a formal EP and structural heart program and are part of a post implantation registry as well as required by the Medicare coverage criteria. 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 LAAC and Watchman procedure have been met. Therefore, we decided that the Plan has to pre-approve a LAAC and Watchman procedure (33340).
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428-NP, A0428-PN), and ground mileage (A0425-NP, A0425-PN) provided on February 8, 2021. 
 
You asked the Plan to pay for the transportation services. You say that the enrollee was being seen for a 
nephrostomy tube malfunction. You also say that the transportation was medically necessary. The Plan denied 
your request. The Plan says the non-emergent transportation by ambulance was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the transportation services. Our reviewer 
says that the transportation services are not medically necessary. Our physician reviewer found transportation 
via ambulance to a scheduled doctor's appointment was not medically necessary. The reviewer found that the 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. The reviewer also found that transportation could have been provided by 
other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's 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 the transportation services have not been met. Specifically, the file shows that 
transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. Therefore, we decided that the Plan does not have to pay for the 
ambulance service, basic life support, non-emergency transport (A0428-NP, A0428-PN), and ground mileage 
(A0425-NP, A0425-PN) provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a portable oxygen concentrator (E0043). 
 
You asked the Plan to preapprove the portable oxygen controller. You say that the portable oxygen 
concentrator is necessary to get you to your appointments. The Plan denied your request. The Plan says your 
physician must provide a written order with supporting documentation to verify the need for the service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The record does not contain a valid physician order. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to preapprove a portable oxygen concentrator (E0043).
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 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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. 
 
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 an office visit (99349) provided September 10, 2019 to September 17, 2019.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the office visit was not filed until May 19, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an office visit (99349) provided September 10, 2019 to September 17, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 31, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the clinical psychologist (CP) will attempt to consult with the enrollee's attending or primary care physician. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with the enrollee's attending or primary care physician nor a record of referral. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visit, and the
specialist office visit provided on May 14, 2021.

You asked the Plan to waive the copayments for the emergency room visit and the specialist office visit. You
say that you have received denials of payment and bills in which you cannot understand. 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 a $90
copayment per visit for emergency care and a $40 copayment per visit for physician/practitioner services,
including doctor's office visits.

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. You have also been asked to pay a $40 copayment for the
specialist office visit. The specialist office visit falls within the "Physician/practitioner services, including
doctor's office visits" benefit category. The record shows these are considered two separate services.

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 copayments for the emergency room visit, and the specialist office visit
provided on May 14, 2021.