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

We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612) and reduction of osseous tuberosity (D7485).

You asked the Plan to pre-approve therapeutic parenteral drugs and reduction of osseous tuberosity. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612) and reduction of osseous tuberosity (D7485).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on May 29, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97110 is not supported.
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, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. Based on
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from March 15, 2021, to March 18, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you shouldn't be charged separately for the 2 inpatient stays. The Plan denied your request. The Plan says the copayment was applied to 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 $200 copayment for each day days 1-5 for each Medicare-covered inpatient hospital stay at a network hospital. 

You have been asked to pay a total of $600 ($200 copayment x 3 days = $600) for the inpatient hospital stay. This service falls within the Inpatient hospital care 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 inpatient hospital stay from March 15, 2021, to March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses provided on February 25, 2021.
You asked the Plan to pay for the progressive lenses. You say that you get an eye exam and $100 allowance on eyeglasses. You say that you do not understand why the services would be denied. The Plan denied your request. The Plan says you are responsible for the progressive lenses as progressive lenses are not covered per your EOC.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Progressive lenses are not listed as a covered benefit in the EOC. We looked at the file and the Plan's rules. Progressive lenses are not listed as a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses provided on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (63081, 63082, 22854) provided on December 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
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, the CPT Code Manual definition of code 63081 is "Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment." The CPT Code Manual definition of code 63082 is "Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure)." The CPT Code
Manual definition of code 22854 is "Insertion of intervertebral biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)." We asked our coding 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 use of codes 63081, 63082, and 22854 is not supported by the records provided. Our coding reviewer found that the documentation does not include amount of bone removed to confirm partial or complete. Additionally, the operative report does not include documentation of intervertebral biomechanical device, therefore code 22854 cannot be confirmed as performed. We looked at this coder'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 the services (63081, 63082, 22854) provided on December 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 6, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 psychotherapy services provided on October 6, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 21, 2021, through February 14, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you should have the preferred copayment because that is what you were quoted. The Plan denied your request. The Plan says the cost share was 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 $440 non-preferred copayment each day one through five for inpatient hospital care.

You have been asked to pay a $440 non-preferred copayment each day one through five for inpatient hospital care. This service within the inpatient hospital care benefit category. You received your care from a non-preferred provider. This means that you have been asked to pay the correct amount based on your contract with the Plan ($440 x 5 = $2,200). 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 inpatient hospital care provided on January 21, 2021, through February 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the specialist office visits provided on March 30, 2021 and April 9, 2021.

You asked the Plan to waive the coinsurance for the specialist office visit. You say that you are being charged 20% coinsurance. You say you have cost share protection. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for provider and professional services at an in-network specialist's office. 

The Plan says you must pay a $32.41 coinsurance and $24.94 coinsurance for the specialist office visits on March 30, 2021 and April 9, 2021. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the specialist office visits on each date of service. Therefore, we decided that the Plan has to waive the coinsurance for the specialist office visits provided on March 30, 2021 and April 9, 2021.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient observation stay from February 3, 2021, through February 7, 2021.
You asked the Plan to waive the copayment for the outpatient observation stay. You say that you don't believe you should be responsible for the cost of observation services. The Plan denied your request. The Plan says the services appear to be correctly billed as observation services and your cost-share is less than the copayment for observation services.
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 $350 copayment per stay for outpatient observation stays. You have been asked to pay a $297.19 copayment for the outpatient observation stay. This service falls within the Outpatient hospital observation benefit category. This means that you have been asked to pay less than or equal to 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 outpatient observation stay from February 3, 2021, through February 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided
on October 28, 2020 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that preventive care
is paid at 100% with a $0 copay in-network or out-of-network. The Plan denied your request. The Plan says the
total liability amount of $106.00 was applied correctly. The Plan also says that the enrollee liability is a
contractual obligation under the Plan and cannot be waived.

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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on October 28, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient psychiatric services provided from March 22, 2021, to March 30, 2021.

You asked the Plan to waive the copayment for the inpatient services. You say that you were unhappy with the accommodations and care provided and feel that you should have been discharged from the hospital sooner than you were. The Plan denied your request. The Plan says the cost-sharing was 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 $300 copayment for each of the first five days of an inpatient psychiatric hospital stay. You will pay $0 for each additional day, up to 190 days. 

You have been asked to pay a $1,500 copayment for the inpatient mental health services. The hospital stay exceeded 5 days in length and was billed for a total of $14,400. You received some discounts through your insurance Plan and the rest was covered. You have been asked to pay $300 for each of the first five days of your stay (5 days x $300 copayment = $1,500). You have not been billed for charges after the fifth day. 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 inpatient psychiatric services provided from March 22, 2021, to March 30, 2021. 

Your complaint about copayment costs and the care/length of stay provided by a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daratumumab/hyaluronidase.

You asked the Plan to pre-approve Daratumumab/hyaluronidase. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 Daratumumab/hyaluronidase. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the requested use of the drug is not FDA-approved. There is insufficient evidence in the compendia and the medical literature to support the use of Daratumumab/hyaluronidase in combination with Ninlaro (Ixazomib) for the treatment of relapsed multiple myeloma. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Daratumumab/hyaluronidase have not been met. Therefore, we decided that the Plan does not have to pre-approve Daratumumab/hyaluronidase.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on September 26, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator rendered on September 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you cannot walk and get out of bed or car since having hip surgery on July 28, 2021. You state you cannot move from the chair by yourself or go to the bathroom and nobody is at home to help you get around. The Plan denied your request. The Plan says the stay 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
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 these services are medically necessary. The Plan
denied your request. The Plan says that your nursing, medical management and rehabilitation needs do not
require an interdisciplinary team approach to delivery of rehabilitation 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. 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 were admitted for polymyalgia rheumatica. Your
medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320) for tooth #5, to be performed by an out-of-network provider.
You asked the Plan to pre-approve endodontic therapy. You say that this service is necessary, and you are having a difficult time finding an in-network provider who is able to provide this service. The Plan denied your request. The Plan says out-of-network dental care is not covered, and the requested provider is not in the Plan's dental network. There are providers who can provide this service in the Plan's network.
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, items or services provided out-of-network are not covered under this benefit. The Plan has providers in network who are able to provide the requested service. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3320) for tooth #5, to be performed by an out-of-network provider.
Your frustration with finding a provider is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.