Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 your medical conditions are stable and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement eyeglasses.

You asked the Plan to pre-approve replacement glasses. You say that the member needs replacement glasses as his initial pair of eyeglasses were stolen. You also say the member picks his eyes due to his schizophrenic condition. The Plan denied your request. The Plan says the member is covered for one pair of standard eyeglasses or contact lenses per calendar year.

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 contract says the member receives one pair of eyeglasses per calendar year. 

We looked at the file and the Plan's rules. The records show that the member received eyeglasses on April 21, 2021 and will not be eligible for another pair of glasses until January 1, 2022. Based on this information, we decided that the Plan's rules for coverage of replacement glasses have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation concerning failure of bilevel positive airway pressure (BIPAP) despite compliantly using the BIPAP.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found there are diagnoses of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and obesity hypoventilation (OHS) syndrome. There are no pulmonary function tests to confirm COPD. There is no documentation CO2 retention with an arterial blood gas test. Medicare does not cover a home ventilator when used as BiPAP, nor in the treatment of OSA or OHS.

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 ventilator have been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
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 for the enrollee.

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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the interim partial denture provided on October 1, 2020, the intraoral complete series x-ray and extractions provided on October 26, 2020, and the partial denture provided on February 10, 2021.
You asked the Plan to pay more for the partial dentures, extractions and intraoral complete series x-ray. You say that you thought insurance took everything because they have dental services. The Plan denied your request. The Plan says the claims reprocessed to apply the in-network benefit for the x-rays and extractions as a onetime exception, but the partial dentures remain denied.
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 is only obligated to pay 50% of the cost for an intraoral complete series x-ray and extractions when received from a network provider. Partial dentures are not a covered benefit. Therefore, we decided that the Plan does not have to pay more for the interim partial denture provided on October 1, 2020, the intraoral complete series x-ray and extractions provided on October 26, 2020, and the partial denture provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical eye exam (92014) and a measurement of the eye (92136) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a medical eye exam and a measurement of the eye. You say that you had a bad eye infection in 2019 and could have lost your eye but this provider oversaw it. You also say that you are requesting this provider because he has learned so much about your eyes and knows where the infection was. You would like this provider to do your surgery. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 records show that you were initially seen by this provider in August of 2018 and the last visit with this provider was December 30, 2019. You were approved to see this provider using Point of Service (POS) benefits, in which you no longer have as of January 1, 2020. The Plan has network providers available who can provide the items/services at issue in
this appeal. The records provided for review do not show that the services at issue are urgent or emergent. 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 a medical eye exam (92014) and a measurement of the eye (92136) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing in the lower left quadrant. We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper right quadrant.
You asked the Plan to pre-approve periodontal scaling and root planing. You say that your teeth are getting worse and you need the deep cleaning to save the teeth you have. You say that you don't want to have them pulled and receive dentures. The Plan says that the x-rays do not show four teeth that need treatment.
We decided that the Plan has to pre-approve periodontal scaling and root planing in the lower left quadrant.
Periodontal scaling and root planing would be indicated in situations where there are four or more involved teeth in a quadrant. The physician reviewer says that it is clear there are four involved teeth in the lower left quadrant. Given there are four involved teeth in the lower left quadrant, there is necessity for the scaling and root planing in that quadrant. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing in the lower left quadrant.
We also decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper right quadrant.
Our physician reviewer says that the upper right quadrant only has three teeth present and would not qualify for scaling and root planing under code D4341. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper right quadrant.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided to the enrollee on March 3, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified.
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 99291 is "critical care visit of 30-74 minutes." We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not include a notation of the time spent providing this service. This information is required as CPT 99291 is a time-based code. 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 critical care services (99291) provided to the enrollee on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are unable to walk to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 12, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you expected to see a different dentist and you were not informed this dentist was not an approved provider. You say that this was all a billing mistake, and this would have been paid if it was submitted correctly. The Plan denied your request. The Plan says the intraoral x-rays, panoramic x-ray and 2D oral/facial photographic images were billed in error and the charges were removed. The Plan also says that the comprehensive oral evaluation is not covered when received by an out-of-network provider.

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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from
January 18, 2021, to February 26, 2021.

You asked the Plan to pay for the home visits. You say that these services were approved as a covered benefit
under the enrollee's plan prior to being rendered. The Plan denied your request. The Plan says the treating
provider is not Medicare certified.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home visits have not been met. This provider is not part of the Medicare program and is not
payable. Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis (99512)
provided from January 18, 2021, to February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the Botox injection and chemodenervation provided on February 8, 2021.
You asked the Plan to waive the cost for the Botox injection and chemodenervation. You say that you were always told no payment was required. You say that you were not aware of your responsibility and you do not have the money to pay. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs and a $45 copayment for specialist physician services at a physician's office. You have been asked to pay a total of $283 for the onabotulinumtoxina injection and chemodenervation.
Service
Allowed Amount
Standard Cost
Member Liability
Injection
$1,190
20%
$238
Chemodenervation
$197.08
$45
$45
TOTAL:
$283
The onabotulinumtoxina injection falls within the "Medicare Part B prescription drugs" benefit category. The chemodenervation falls within the "Physician/Practitioner services, including doctor's office visits" 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 cost for the Botox injection and chemodenervation provided on February 8, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis 0.05% drops.

You asked the Plan to pre-approve Restasis drops. You say that the enrollee has been continuously using this drug for the last 6 months. You also say that there has been an improvement in the enrollee's condition. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis 0.05% drops.

Benefits for Restasis drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift.
You asked the Plan to pre-approve a seat lift. You say that you need this item. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We looked at the file and Medicare rules. The submitted medical records do not show that you are completely unable to stand up from a regular armchair or any chair in the home. Based on this information, we decided that Medicare rules for coverage of a seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 12, 2021.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental services provided by an out-of-network provider are not covered under the Plan's supplemental 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 dental services provided by an out-of-network provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided November 28, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that you did not request the ambulance services and you do not believe you should be responsible for the cost. The Plan denied your request. The Plan says the copayment has been 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 $250 copayment copayment for each one-way Medicare-covered ground trip. 

You have been asked to pay a $250 copayment for the ambulance transport. This service falls within the Ambulance Services 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 ambulance service, basic life support, emergency transport (A0429) provided November 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on April 14, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you were told you would not be charged for this service. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, this service is covered at 100% per calendar year when services are rendered by an in-network provider. The Plan also says that you received a first intraoral periapical x-ray (D0220) on March 3, 2021, which was paid for by the Plan. The Plan contacted
the provider and though this service is not covered by the Plan, the provider stated that as a courtesy, the charge for the first intraoral periapical x-ray (D0220) has been written off, and you now have a $0 balance. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on April 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided on November 2, 2020.

You asked the Plan to pay for the laboratory testing. You say that this testing meets the requirements for coverage. You also say that this testing is medically reasonable and necessary. 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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided on November 2, 2020.