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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140).

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you wanted a second opinion and believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140), your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that a continued stay at the skilled nursing facility is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of continued SNF 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 continued SNF care. Our reviewer says that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that at the time of the admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning; there were no skilled nursing needs. The enrollee did not require skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care. She did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however her function had plateaued and she did not require any further inpatient skilled rehabilitation services.

The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. The member required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you need more therapy. The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submittd records show that you had a spinal decompression surgery on March 2, 2021. You received oral medications and had stable vital signs. You were effectively treated for pain. You received physical and occupational therapy and need assistance with functional mobility, including walking 100 feet with a rolling walker. You need varied assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require an the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery.

You asked the Plan to pay for the surgery. The Plan denied your request. The Plan says that your health Plan does not have out of network benefits. A prior authorization must have been obtained before services were rendered and it 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for surgery.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan of the head or brain.

You asked the Plan to pay for the CT scan. You say that the enrollee was active. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the CT scan of the head or brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bridges for teeth # 2, 3, 4, 5, & 6, and 29, 30, & 31.

You asked the Plan to pre-approve the bridges. You say that the bridges are medically necessary. The Plan
denied your request. The Plan says the documentation does not indicate any specific needs or conditions that
preclude use of a removable prosthesis.

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. The Plan covers the bridges
when the services are medically necessary and reasonable.

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 bridges. Our reviewer says that the
brides are not medically necessary. Our physician reviewer found the documentation that was provided did not
support the need for fixed bridges to replace the missing posterior teeth in this case rather than removable
prostheses.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the bridges have not been met. Therefore, we decided that the Plan does not
have to pre-approve bridges for teeth # 2, 3, 4, 5, & 6, and 29, 30, & 31.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with the amount you are being asked to pay. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $40 copayment for physician/practitioner services/in-network/provider services/specialist's office.

You have been asked to pay a $40 copayment for a specialist office visit. The total amount you are being asked to pay is $80 ($40 x 2 visits = $80). A specialist office visit falls within the physician/practitioner services/in-network/provider services/specialist's office 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 a specialist office visit provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 9, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910), the unspecified preventive service (D1999), and the application of fluoride varnish (D1206) provided on September 22, 2020.

You asked the Plan to reimburse you for the dental services. You say that you paid for the dental services in full on the date the services were rendered. You say that you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for services that you receive from a provider who has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910), the unspecified preventive service (D1999), and the application of fluoride varnish (D1206) provided on September 22, 2020.
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 you need rehab. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital with a right foot infection. You underwent a right below knee amputation. The physical therapy note states you need assistance with standing and sitting and using a rolling walker. You are able to walk 10 feet with the walker. You d not require the intensity of services in an IRF. Specifically, you are not shown to need 15 hours per week of rehabilitative services and regular physician evaluation.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider.

You asked the Plan to waive the copayment for an ultrasound. You say that you were told that this would be covered. You say that you would like this copayment paid. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $160 copayment for outpatient diagnostic tests/in-network/radiological diagnostic service.

You have been asked to pay is $156.93 which is less than your copayment amount of $160 for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/in-network/radiological diagnostic service 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 an ultrasound provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for DRG revision for the inpatient hospital services.

You asked the Plan to pay for the inpatient hospital services. You say that you do not agree with this denial and is formally appealing and requesting review of the entirety of the medical record in this case. The Plan denied your request. The Plan says that the plan says payment of DRG 871 is not supported. The medical records submitted supports DRG 202.

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 change DRG 871 to DRG 202. In this case specific records or information was required to substantiate the plans denial. The required records were missing from the original file. A request for information was sent to the health plan. As of the date of this letter, the plan has not responded to our request and/or submitted the required records Therefore, we decided that the Plan has to pay for DRG revision for the inpatient hospital services.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you went for a screening colonoscopy not a diagnostic colonoscopy. The Plan denied your request. The Plan says there was a polyp issue making the colonoscopy a diagnostic colonoscopy.

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 $295 copayment for Outpatient Surgery.

You have been asked to pay a $295 copayment for the diagnostic colonoscopy. the diagnostic colonoscopy falls within the Outpatient Surgery 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 diagnostic colonoscopy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn.

You asked the Plan to pre-approve Gelsyn. You say that the requested Gelsyn is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Gelsyn. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies. He has failed conservative treatment, Gelsyn injections have been requested. The health plan denied coverage for the Gelsyn as the plan requires a trial of drug(s) Orthovisc and Monovisc before they will approve the requested drug. Based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 enrollee has knee pain. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or medically necessary.

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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the requested device is considered experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lesion removal provided by an out-of-network.

You asked the Plan to pay for the office visit and lesion removal. The Plan denied your request. The Plan says there were in-network providers available.

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 the office visit and lesion removal provided by an out-of-network.