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

 We decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) provided September 23, 2021.  You asked the Plan to pay for the orthosis and sleeve. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says The services are not supported in the medical records received.  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 orthosis and sleeve. 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 reported severe bilateral knee pain and was diagnosed with bilateral primarily osteoarthritis of the knees. Physical findings did not include a drawer test and varus/valus testing was negative. Due to the enrollee's documented examination not showing sufficient objective evidence of a measurable instability of both knees, the enrollee does not clearly meet the criteria for orthoses and sleeves.  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 orthosis and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) provided September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).  You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.  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 a guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a flexwalk system with multiaxial ankle (L5981, L5968).  You asked the Plan to pre-approve a flexwalk system with multiaxial ankle. You say that this is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that the requested equipment is covered for beneficiaries whose functional level is 3 or above.  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 flexwalk system with multiaxial ankle. Our reviewer says that the requested prosthetic equipment is not medically reasonable and necessary. Our physician reviewer found the documentation does not reveal objective treating medical provider/physician progress notes supporting that the patient is a K3 ambulator.   The documentation from the prosthetist indicates the patient uses his prosthesis "almost every day." It is not clear if the patient uses another assistive device as well which would not be consistent with K3 ambulation. There is documentation that the patient's TMA makes him unsteady and he uses a cane which does not support K3 ambulation. There are no objective medical progress notes from the physician supporting that the patient is a K3 functional level.  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 flexwalk system with multiaxial ankle have not been met. Therefore, we decided that the Plan does not have to pre-approve a flexwalk system with multiaxial ankle (L5981, L5968).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for comprehensive eye exam (92004) provided October 15, 2021.  

You asked the Plan to pay for the vision services. You say that you were told by a representative that your eye exam was covered if filed as medical. The provider was unable to file as medical, therefore you are requesting reimbursement. The Plan denied your request. The Plan says this provider is not eligible to participate in Medicare.  

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.       

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92004) provided October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on June 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says both the referring and attending providers are all non-participating with the Plan, and the non-participating provider did not follow the plan's rules to request authorization for out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on June 1, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve the FreeStyle Libre CGM. You say that you would like reconsideration because this system has been extremely helpful in allowing the member to monitor his blood glucose level throughout the course of the day, and provides detailed information that assists with medication adjustments and adjustment of daily dietary and lifestyle choices in order to provide better diabetes control. The Plan denied your request. The Plan says the records do not support that the member uses insulin at least 3 times daily.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 17, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says Medicare only covers ambulance transports and services provided during that transport. This procedure is statutorily excluded from payment and there is no Medicare reimbursement as no transportation occurred.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.    The ambulance company did not provide transport services on August 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.   Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services (G0151 and G0157) and skilled nursing services (G0299) provided from June 7, 2021, to July 6, 2021.  You asked the Plan to pay for the physical therapy services and skilled nursing services. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  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 pay for the physical therapy services provided from July 1, 2021, to July 6, 2021. Our reviewer says that the requested home health (HH) physical therapy (PT) was not medically necessary or reasonable. Our physician reviewer found the provided documentation is of insufficient quantity and quality to show that the enrollee had an acute decline in function, was in need of skilled HH PT, was reasonably expected to improve with HH PT, or was in need of such therapy to maintain his level of function.  Medicare rules also say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  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 physical therapy services have not been met. The enrollee ended Medicare Hospice benefits on June 6, 2021. The physical therapy services and skilled nursing services provided from June 7, 2021, to June 30, 2021 in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the physical therapy services (G0151 and G0157) and skilled nursing services (G0299) provided from June 7, 2021, to July 6, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve cochlear implants for the enrollee.  You asked the Plan to pre-approve the implants. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee has enough residual hearing with current hearing aids for activities of daily living.  The Plan must follow Medicare rules. Medicare rules say that cochlear implants can be covered if specific indications are 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 the implants. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is a diagnosis of bilateral severe to profound sensorineural hearing loss (SNHL) as shown on previous audiologic testing, with decreasing benefit from hearing aids. Secondly, the enrollee demonstrated the cognitive ability to use auditory clues, such as lip reading, and also communicated using American Sign Language. He also expressed willingness and ability to participate in extended follow-up of at least 6-12 months to reach optimal cochlear implant performance. Thirdly, the enrollee is structurally suited for implantation, with normal internal auditory canals and cochleae and no evidence of ear infection. An addendum to the 9/1/21 note stated that the mastoids were normal in appearance. Fourth, there were no reported contraindications to surgery. Temporal bone and internal auditory canal anatomy was normal as previously noted. The enrollee had no evidence of active middle ear disease, and the enrollee expressed understanding of the medical plan and the ability to participate in aural rehabilitation. Finally, the cochlear implants appear to be recommended in accordance with FDA-approved labeling. In summary, the requested services for bilateral cochlear implantation meet Medicare criteria for 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 implants have been met. Therefore, we decided that the Plan has to pre-approve cochlear implants 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CMG).  You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.     We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CMG).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 7, 2021.  You asked the Plan to pay for the dental service. You say that your crown broke off. You say that you were referred to the provider in this case. You also say that the provider would not do the extraction without the examination treatment plan. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit 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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 26, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210) to be provided by an oral surgeon.  You asked the Plan to pre-approve the dental services. You say that you do not understand why your insurance does not cover what you need. You also say that you do not have any money to pay this bill. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.  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 dental services are not among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120) to be rendered by an out-of-network (OON) provider.  You asked the Plan to pre-approve the complete dentures. You say that you are unable to get out of your wheelchair, and the requested provider is the only one who can perform the work while you are in your chair. The Plan denied your request. The Plan says as of June 24, 2020, the provider no longer accepts your dental plan. The Plan also says that OON benefits are not available on your plan.  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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120) to be rendered by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency room (ER) services you received from June 15, 2021, to June 16, 2021.  You asked the Plan to waive the copayment for the ER services. You say that you would like help with this bill. 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 $120 copayment for emergency room services.   You have been asked to pay a $120 copayment for the ER 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 copayment for emergency room (ER) services you received from June 15, 2021, to June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.  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 is currently undergoing treatment at an acute care hospital (ACH) for pneumonia in the setting of pulmonary fibrosis and lung cancer.  The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve septoplasty and submucous resection of turbinate partial/complete for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a deviated nasal septum.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found although the computed tomography (CT) scan report mentioned a right-sided septal deviation, two previous consecutive clinical exams reported no septal deviation or turbinate hypertrophy. The available clinical documentation did not mention nasal symptoms such as congestion or obstruction, nor was there mention of septoplasty or turbinate reduction in the enrollee's management plan. In summary, the requested septoplasty and turbinate reduction do not meet criteria for being medically necessary and 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve septoplasty and submucous resection of turbinate partial/complete for the enrollee.