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

We decided that the Plan has to pre-approve therapeutic continuous glucose monitor sensors.
You asked the Plan to pre-approve therapeutic continuous glucose monitor sensor (K0553). You say that the enrollee is using a CGM and needs sensors The Plan denied your request. The Plan says that criteria is not met for a CGM.
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 provided medical records to support that the enrollee's insulin regimen does not meet criteria. Therefore, we decided that the Plan has to pre-approve therapeutic continuous glucose monitor sensors.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
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 Opdivo. Our reviewer says that the requested use of Opdivo is not supported. Our physician reviewer found Opdivo is Food and Drug Administration-approved for the treatment of non-small cell lung carcinoma; however, based on National Comprehensive Cancer Network guidelines, its use is not supported with evidence of disease progression on a PD-1/PD-L1 inhibitor. The enrollee has been treated with such an agent (pembrolizumab) and has shown evidence of disease progression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic
x-ray (D0330) provided on February 24, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you did
receive these services in 2019, but never heard back from that dentist office. The Plan denied your request. The
Plan says these services exceed the maximum counts allowed per period.
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, comprehensive oral evaluation
(D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record
shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on May 20,
2019, and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) benefits have been
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation
(D0150) and panoramic x-ray (D0330) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on May 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary visit. You say that the service was 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 domiciliary visit provided on May 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 24, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient lift and related items/services provided to the enrollee from February 23, 2021 to March 4, 2021.
You asked the Plan to pay for these items. You say that these items were necessary for your husband. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the patient lift and related items/services provided to the enrollee from February 23, 2021 to March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedures you had at an outpatient hospital facility on September 22, 2020, and December 22, 2020.
You asked the Plan to waive the copayment for the cystourethroscopy procedures. You say that these services should be considered diagnostic procedures/tests, not surgery. You say that you had this done in an office, not a hospital. The Plan denied your request. The Plan says you were charged these copayments 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 $150 copayment for surgery and other services in an outpatient hospital facility. You have been asked to pay a $150 copayment for the cystourethroscopy procedures. Medicare considers cystourethroscopy (code 52000) to be a surgical service, not a diagnostic test. Records show that the facility where you had these services is considered an outpatient hospital facility, not an office setting. That is why the cystourethroscopy procedures fall within the surgery and other services in an outpatient hospital facility 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 cystourethroscopy procedures you had at an outpatient hospital facility on September 22, 2020, and December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips beyond the initial 24.
You asked the Plan to provide additional transportation. You say that you need this transportation to get to your appointments. The Plan denied your request. The Plan says trips beyond the 24 covered by the Plan's supplemental benefit 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 24 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's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips beyond the initial 24.
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 meets the criteria or coverage and IRF care is medically necessary. You say that the denial of IRF care could jeopardize the enrollee's health. You say that the enrollee is stable and suitable for transfer. You say that the enrollee's current medical conditions, treatment, comorbidities, and past medical history supports the need for acute intensive rehabilitation. The Plan denied your request. The Plan says the enrollee can get the therapy needed at a lower level of care.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness, end stage renal disease and vascular congestion. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded 76705 provided on May 27, 2021.
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 for the ultrasound services has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 ultrasound services coded 76705 provided on May 27, 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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
February 28, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were unaware that the ER had a 
$90 copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $90 
copayment for emergency room visits. 

You have been asked to pay a $90 copayment for the ER visit. 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 emergency room (ER) visit you had on February 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging for arm pain.
You asked the Plan to pre-approve magnetic resonance (eg, proton) imaging, upper extremity, other than joint (73218). You say that you have arm pain and need an MRI. The Plan denied your request. The Plan says there is no physician order for the MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We looked at the file and Medicare rules. There is no order from your PCP or specialist for the requested service. MRI is not a service that you can get without approval from your doctor. Based on this information, we decided that Medicare rules for coverage of magnetic resonance (eg, proton) imaging, upper extremity, other than joint (73218) have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging for arm pain.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81405, 81406, 81407, 81408, 81479, and 81439) provided on October 27, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81405, 81406, 81407, 81408, 81479, and 81439) provided on October 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the durolane injection provided on November 13, 2020.

You asked the Plan to waive the coinsurance for the durolane injection. You say that the charges from 2019 were reviewed and satisfied. You say that the charges from 2020 would be a hardship and you want this reviewed to make sure you truly owe this much. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for each Medicare-covered Part B drug.

You have been asked to pay $1,948.80, which is 20% of the allowed amount for the durolane injection. The allowed amount is $9,744 (20% x $9,744 = $1,948.80). The durolane injection 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 the durolane injection provided on November 13, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray examination (74220), provided on April 8, 2021.
You asked the Plan to pay for the x-ray exam, 74220. You say that this is not a duplicate charge and should be
processed for payment. The Plan denied your request. The Plan says the denial of payment for this service is
correct, because codes 74220 and 74246 have a procedure-to-procedure (PTP) edit which does not allow
payment of this 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 x-ray exam
code 74220 has a bundled relationship with code 74246 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for an x-ray examination (74220), provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the full mouth debridement.
You asked the Plan to pre-approve the full mouth debridement. The Plan denied your request. The Plan says that the service cannot be approved.
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 full mouth debridement once every 3 years. We looked at the coverage rules, the case file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the full mouth debridement have been met. Specifically, the Plan says that full mouth debridement cannot be provided within 12 months of a cleaning or oral evaluation. Neither the dental contract nor Evidence of Coverage submitted lists this benefit limit for the code requested. The definition of the requested code only says that D4355 cannot be completed on the same day as D0150. The Explanation of Benefits submitted does not show that full mouth debridement was already provided on June 29, 2021 or within three years to exhaust the benefit. Therefore, we decided that the Plan has to pre-approve the full mouth debridement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a queen size adjustable bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says there must be a requirement for frequent changes in body position or need for immediate changes in body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found in this case, the
documentation doesn't support that you have a condition that requires frequent positioning of the bed and
mattress to alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in
a way that an ordinary bed is not able to.
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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a queen size adjustable bed.