Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a sacral nerve stimulator implantation.
You asked the Plan to pre-approve a sacral nerve stimulator implantation. You say that the enrollee has a history of effective sacral nerve stimulator implantation, but a unit need to be removed due to contamination when the surgical wound opened. You say that the re-implantation of the device is reasonable in the circumstances, since the device was previously approved. The Plan denied your request. The Plan says that the records provided do not show that the enrollee's bladder can hold at least 100 ml of urine, at least 50% symptom improvement, and a qualifying condition for the procedure.
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for certain medical indications. 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 sacral nerve stimulator implantation. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found interstim revision/replacement may be required in up to 49% of patients. The enrollee required removal due to wound separation and infection. Interstim replacement is appropriate and indicated. 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 sacral nerve stimulator implantation have been met. Therefore, we decided that the Plan has to pre-approve a sacral nerve stimulator implantation.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from June 29, 2019 to July 12, 2019.You asked the Plan to pay for the inpatient hospital services. You say that the enrollee suffered a severe stroke which resulted in the revocation of the enrollee's hospice benefits.The Plan denied your request. The Plan says for inpatient hospital claims, whoever is liable on the date of admission will cover the entire stay. The Plan also says that Original Medicare is responsible for the inpatient hospital stay because the enrollee was under hospice care.Medicare rules 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.The enrollee ended Medicare Hospice benefits on June 29, 2019.The Plan says for inpatient hospital claims, whoever is liable on the date of admission will cover the entire stay. The Plan also says that Original Medicare is responsible for the inpatient hospital stay because the enrollee was under hospice care.Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from June 29, 2019 to July 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the services. You say that you had a bad experience with a previous provider. The Plan denied your request. The Plan says these services are available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 extractions and panoramic x-ray provided November 21, 2019.
You asked the Plan to pay for the 3 extractions and panoramic x-ray. You say that you assumed these services would be covered by your insurance. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says these services are not covered under 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 plan only covers bitewing x-rays and does not provide a benefit for panoramic x-rays or extractions. Therefore, we decided that the Plan does not have to pay for the 3 extractions and panoramic x-ray provided November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heart ultrasound provided on October 19, 2019.You asked the Plan to waive the copayment for the heart ultrasound. You say that you have never had an EKG before. You say that you are entitled to one EKG with no charge.The Plan denied your request. The Plan says the copayment 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 a $95 copayment for diagnostic procedures and tests at an in-network outpatient hospital.You have been asked to pay a $95 copayment for the heart ultrasound. The heart ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the heart ultrasound was performed. 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 heart ultrasound provided on October 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that the enrollee needs short-term therapies so she can return to living on her own.The Plan denied your request. The Plan says the enrollee does not have any skilled nursing needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the enrollee requires oversight of her medical conditions and medication management. She has cognitive impairment and would not be expected to be able to self-monitor her medical conditions. However, her medical conditions are stable and there are no unaddressed medical issues. She receives assistance from her family members in terms of managing her medications and observing for changes in her medical condition. She is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. There are skilled needs, but they do not need to be provided on a daily basis.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) admission and services.
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 that it appears that needed therapy services could be reasonably provided at a lower level of care such as at home with home health care services or in custodial care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.We looked at this physician's review, thefile, 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: 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 the SNF services. You say that the enrollee requires physical therapy and podiatry services. You say that SNF care is required to help improve the enrollee's independence. The Plan denied your request. The Plan says the criteria for coverage of SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 61-year-old man with a diagnosis of pneumonia with an exudative right pleural effusion. The enrollee had a VATS procedure with partial decortication on the right. The enrollee was extubated on February 15, 2020. A progress note from February 25, 2020 shows that the enrollee still requires soft wrist restraints due to pulling on his trach collar and scalp staples, as well as biting on his sheets. The records showed bilateral lower lobe infiltrates, with left base being worse compared to previous. The enrollee completed Zosyn. The enrollee's mental status and cognition were impaired on February 25, 2020. He continued to require total assist for all functional skills and to maintain static/dynamic sitting balance. The enrollee is having difficulty following motor commands. As a practical matter, the documentation does not support that the enrollee is stable for transfer to an SNF with worsening infiltrate and impaired mental status. 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device and appliances provided on August 14, 2019.You asked the Plan to pay fora pneumatic compression device (E0675) and appliances. You say that the enrollee's physician ordered the device to reduce the chancesof deep vein thrombosis during surgery.The Plan denied your request. The Plan says items used for preventative services or function are excluded from coverage.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device and appliances provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean automatic medication dispenser.You asked the Plan to pre-approvean automatic medication dispenser.The Plan denied your request. The Plan says this item does not serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvean automatic medication dispenser.
Appeal type: Drugs
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 72 of the Plan's 2020 EOC.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Euflexxa is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have osteoarthritis of the knee, but there is no documentation that you have tried and failed Monovisc, Orthovisc, or Synvisc, which have similar effectiveness to Euflexxa. There is no support that Euflexxa is reasonable and medically necessary over the other alternative options.
We looked at this physician's review, the file, and Medicare rules. 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 Euflexxa injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 11, 2019 to October 29, 2019 by an OON provider.You asked the Plan to pay for the skilled nursing services. You say that the enrollee was transferred from the medical center to the rehabilitation center because of trauma and post-traumatic stress disorder.The Plan denied your request. The Plan says the services were rendered by a non-Plan provider. The Plan also says that prior authorization was not 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 has network providers available who can provide 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 the skilled nursing services provided from September 11, 2019 to October 29, 2019 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the acute inpatient rehabilitation facility admission is medically necessaryfor the enrollee.The Plan denied your request. The Plan says IRF care 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 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 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 that based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and a regular physician evaluation. The enrollee's needs can be met at a lower level of care.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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. The Plan denied your request. The Plan says that your request exceeds benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Q Logic Controller/Joystick Module (K0108).
You asked the Plan to pre-approve controller/joystick module. You say that you need a new power wheelchair. The Plan denied your request. The Plan says Medicare rules state that this is already included in the expandable controller E2377 and harness E2313, and cannot be requested separately.
The Plan must follow Medicare rules. Medicare rules state that code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. We looked at the file and Medicare rules. 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 Q Logic Controller/Joystick Module (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on November 8, 2019.
You asked the Plan to waive the copayment for the biopsy. You say that the services were provided in the doctor's office as a follow up. You say that you are appealing the bill. The Plan denied your request. The Plan says the copayment 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 a $400 copayment per date of service for outpatient surgery at an outpatient hospital facility.
You have been asked to pay $265.10, which is less than the standard $400 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the biopsy was billed by the hospital. 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 biopsy provided on November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage You asked the Plan to pre-approve additional mileage for routine transportation. You say that you have an appointment to see your glaucoma specialist. You are half blind and is relying on transportation to attend your doctor appointments.The Plan denied your request. The Plan says This request exceeds the plan's mileage limit. The mileage between your residence and the provider's address is 142 miles. This is 92 miles over the benefit limit of 50 miles per one way trip.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 one-way transportation trips per year and each one-way trip must not exceed 50 miles per each one-way trip trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.