Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2025, V2781) purchased from an out-of-network provider on January 27, 2021.
You asked the Plan to pay for the eyeglasses. You say that you always get your glasses from this provider and the Plan has always covered them. You say you looked at your Annual Notice of Changes, and the booklet did not mention that there was a change in the vision coverage. You say these should be covered like they always have. The Plan denied your request. The Plan says out-of-network services are not covered. The Plan also says this change was not listed in the Annual Notice of Changes for 2021 because out-of-network vision care has not been covered in previous years.
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. The Plan covers up to $250 for routine vision hardware every 2 years when purchased from an in-network provider.
We looked at the file and the Plan's rules. The Plan's contract clearly states that you must see an in-network vision provider to receive routine vision benefits. Your Plan is also an HMO (Health Maintenance Organization) type Plan. HMO Plans generally always require enrollees to receive all care from in-network providers, except when out-of-network services are emergent or pre-approved. The Plan had in-network providers available who could have provided the eyeglasses, and we found no exception that would require the Plan to pay for these services. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2025, V2781) purchased from an out-of-network provider on January 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health aide or certified nursing assistant, per hour (S9122) provided from November 10, 2020, to November 21, 2020, and December 22, 2020, to December 31, 2020.
You asked the Plan to reimburse you for the home health aide services. You say that the services should be
covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the
enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage
member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to reimburse you for the home health aide or certified nursing assistant,
per hour (S9122) provided from November 10, 2020, to November 21, 2020, and December 22, 2020, to
December 31, 2020.
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. You say that you would benefit from continued skilled therapy due to blood pressure treatment. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 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, 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) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (62324) and drug management (01996) provided
from June 16, 2020, to June 19, 2020.

You asked the Plan to pay for an injection and drug management. You say that these services are supported in
the records. The Plan denied your request. The Plan says these services are not documented.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT codes 62324 and 01996 are not supported in the medical record. Specifically, the submitted documentation does not include medical records for the billed dates of service. Without this information, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of an injection and drug management have not been met. Therefore, we decided that the Plan does not have to pay for an injection (62324) and drug management (01996) provided from June 16, 2020, to June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (83036, 84439, 84443, 80061, 82306, 82728 and 82977) provided on July 14, 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 above, are not covered. 

The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (83036, 84439, 84443, 80061, 82306, 82728 and 82977) provided on July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient behavioral hospital services provided from January 1, 2021 to January 31, 2021.

You asked the Plan to pay for the inpatient behavioral hospital 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. Medicare rules say Occurrence Span Code 74 is present on claims when there is an interrupted stay where the enrollee returned to the same IPF within 3 days. The file does not show that the enrollee returned to the same IPF within 3 days. Therefore, we decided that the Plan does not have to pay for the inpatient behavioral hospital services provided from January 1, 2021 to January 31, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the bilateral screening mammography (77067) and screening 3D breast mammography (77063) provided on December 12, 2020
You asked the Plan to pay for the bilateral screening mammography and screening 3D breast mammography. The Plan denied your request. The Plan says that these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
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 did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the bilateral screening mammography (77067) and screening 3D breast mammography (77063) provided on December 12, 2020
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the bone replacement graft for ridge preservation (D7953) provided on
July 31, 2020.
You asked the Plan to pay for the bone replacement graft. You say that you believe this service should be
covered. The Plan denied your request. The Plan says that this service is not covered.
The Plan must follow Medicare rules. The rules say that the health plan must provide you with a clear and
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under
your plan contract including applicable conditions and limitations and any other conditions associated with the
use or receipt of the benefits.
The EOC states that bone replacement graft is a covered service. The contract does not clearly state specific
dental codes or types of bone replacement grafts that are, or are not, covered by the Plan. You received a bone
replacement graft and reasonably believed it would be covered, because it is listed as a covered benefit.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the bone replacement graft have been met. Therefore, we decided that the Plan has to pay for the
bone replacement graft for ridge preservation (D7953) provided on July 31, 2020.
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 pay for the emergency room services, the observation services and ancillary charges provided from January 11, 2021 January 14, 2021.

You asked the Plan to pay for the emergency room services, the observation services and ancillary charges. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of emergency room services, observation, and ancillary charges are upheld because the charges should be carved out and billed separately from inpatient charges. The Plan says that corrected claims can be submitted for review.

The Plan must follow Medicare rules. Medicare rules say that when an inpatient admission is found to be not reasonable and necessary, the Centers for Medicare & Medicaid Services (CMS) will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient.

We looked at the file and Medicare rules. The rules say if an enrollee was admitted as an inpatient and payment cannot be made for inpatient care leading to claim denial, the provider can be paid for the emergency room services and observation services provided prior to formal admission, if they submit a standard Part B outpatient hospital claim. Therefore, we decided that the Plan does not have to pay for the emergency room services, the observation services and ancillary charges provided from January 11, 2021 January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darbepoetin Alfa.

You asked the Plan to pre-approve Darbepoetin Alfa. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria have 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 Darbepoetin Alfa. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 76-year-old woman who has been diagnosed with high-risk Myelodysplastic syndromes (MDS). The enrollee has previously had prior chemotherapy for breast cancer. In this case, there are no epogen levels provided that would indicate that the requested drug is being prescribed for a covered indication based on the relevant NCD. This request is otherwise not medically reasonable and necessary for the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darbepoetin Alfa have not been met. Therefore, we decided that the Plan does not have to pre-approve Darbepoetin Alfa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on February 25, 2021 and March 25, 2021.

You asked the Plan to waive the coinsurance for the drugs. You say that you believed you were only responsible for the specialist copay. The Plan denied your request. The Plan says that you are responsible for a 20% coinsurance.

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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the drugs. The drugs fall 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 Part B drugs provided on February 25, 2021 and March 25, 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 LTACHs do not provide clinical advantage over a non-LTACH acute care
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 does not require services at the LTACH that are not available at the acute
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the
current acute care facility. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The health plan has approved ongoing care
in the current acute care facility.

The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Pertuzumab injection (J9306) and the Trazimera injection (Q5116) provided on January 14, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.

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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay $1,466.86 ($7,334.34 x 20% coinsurance) for the Medicare Part B drug injections provided. 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 Pertuzumab injection (J9306) and the Trazimera injection (Q5116) provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on February 9, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up visit after surgery and there should be a $0 copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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 did not send information about the level of care in which the surgery was provided. This means we are unable to determine if the cost sharing amount you have been asked to pay is correct. Therefore, we decided that the Plan has to waive the copayment for the specialist office on February 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on
September 29, 2020.

You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your
request. The Plan says that documentation submitted did not sufficiently document the member's medical
condition to support the medical necessity for the billed supply code; nor did documentation indicate the
provider discussed the need for the billed supply code.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection of upper or middle spine facet joint using imaging guidance, third and any additional level (64492).

You asked the Plan to pre-approve the injection of upper or middle spine facet joint using imaging guidance, third and any additional level. You say that this requested additional injection is medically necessary. The Plan denied your request. The Plan says the criteria for a third level injection have not been met.

The Plan follows Medicare rules. Medicare rules say that diagnostic cervical facet blocks are recommended at up to two joint levels to address axial neck pain. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection of upper or middle spine facet joint using imaging guidance, third and any additional level. Our reviewer says that the requested third level injection is not medically reasonable and necessary. Our physician reviewer found that the review indicates that the enrollee is a 50-year-old member with a diagnosis of cervicalgia. Prior treatment included physical therapy in 2017 and 2018, stretching, chiropractic, and massage. Prior medications included Cyclobenzaprine, Meloxicam, Acetaminophen, and Gabapentin. On physical examination, there was right occipital nerve tenderness and tenderness at the neck. The review has determined the original requested procedure was previously denied due to a plan for 3 joint levels. On appeal, a revised plan for two levels is noted and is reasonable. However, the requested codes do not all correspond to twos levels. The review has determined that the request for the third joint level facet joint injection (64492) is not medically necessary or 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 injection of upper or middle spine facet joint using imaging guidance, third and any additional level have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection of upper or middle spine facet joint using imaging guidance, third and any additional level (64492).