Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
October 20, 2020.
You asked the Plan to pay for the office visit. You say that the attached records support the medical necessity.
The Plan denied your request. The Plan says prior authorization was required but 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
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 provided by an out-of-network
provider on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar facet joint injection.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the cause of the back pain has not been ruled out, and conservative treatments are ongoing.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that in this case, the record indicates that the pain began a week after foot surgery with resultant temporary gait disturbance. The enrollee has had functional improvement with physical therapy that is ongoing. The elements of the coverage criteria are not satisfied.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vacuum pump (L5781) and alignable endoskeletal system below knee (L5910).
You asked the Plan to pre-approve the vacuum pump and alignable endoskeletal system below knee. You say that these items are medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 vacuum pump and alignable endoskeletal system below knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation in the physician progress note why the patient is unable to use his prior prescribed alignable system (L5910). There is no evidence of edema, hyperhidrosis, skin or other issues documented on a physical exam or in the physician's note that indicate the need for a vacuum pump (L5781). The requested items exceed the patient's medical need and are not 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 the vacuum pump and alignable endoskeletal system below knee have not been met. Therefore, we decided that the Plan does not have to pre-approve the vacuum pump (L5781) and alignable endoskeletal system below knee (L5910).
Appeal type: Surgery
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Explanation of decision
We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertiflex procedure has not been proven by medical studies to be helpful for enrollee's problem.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before coverage can be approved.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the otolaryngology visit you had on February 24, 2021.

You asked the Plan to waive the copayment for the otolaryngology visit. You say that this was a follow-up visit from your procedure, so it should be covered in full. The Plan denied your request. The Plan says this copayment was charged 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 $20 copayment for specialist office visits.

You have been asked to pay a $20 copayment for the otolaryngology visit. Records show that you had a surgical endoscopy on January 18, 2021. The endoscopy you received was a minor procedure that has a 0-day postoperative period. That means that follow-up visits are not included in the payment for the surgery itself and that copayments for follow-up visits can apply. 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 otolaryngology visit you had on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by a periodontist.
You asked the Plan to pre-approve the requested services. You say that you are having a problem with bone loss in the gum line. The Plan denied your request. The Plan says the requested service is non-covered.
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.
We looked at the file, and Medicare rules. Your plan only covers services when provided by a participating general dentist. Based on this information, we decided that the Plan's rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by a periodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and battery.
You asked the Plan to pre-approve a power wheelchair and battery. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the enrollee's condition can be improved by a walker, cane or manual wheelchair. The documentation supports that the enrollee is able to walk 200 feet with a walker and a right platform attachment. In addition, the enrollee has enough upper extremity strength to self-propel a manual wheelchair to performed mobility related activities of daily living in the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and battery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 8, 2021 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you saw your primary care doctor. You say that this
should not have a copayment. The Plan denied your request. The Plan says prior authorization was not
obtained. The Plan says that the rendering physician does not participate in your specific HMO plan.
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 an office visit provided on February 8, 2021 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says step therapy criteria have not been 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 Prolia. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found in this case, the Plan
requires a trial of Zoledronic acid or a history of osteoporosis-related fracture before they will approve the
requested drug, Prolia. Based on the medical records provided, the patient has not tried and failed the required
drug and has no reported history of an osteoporosis-related fracture. There is no indication that the plan's
required drug would likely be less effective and/or likely have adverse effects for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a
participating provider on March 15, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you would like this
copayment waived. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $100 copayment for ambulance services.
The enrollee has been asked to pay a $100 copayment for ambulance services. Ambulance services falls within
the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
ambulance services provided by a participating provider on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).

You asked the Plan to pre-approve the SSBCI benefit. You say that you qualify for this benefit with a condition that is not on the list. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefits for the Chronically Ill (SSBCI) for 2021.

Medicare generally does not cover supplemental benefits. However, the Plan offers a special supplemental benefit for the chronically ill (SSBCI) that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SSBCI benefit have not been met. Specifically, the record does not show you have been diagnosed with any of the qualifying diagnoses, you do not require intense care coordination, you do not have a high risk for hospitalizations or high risk for adverse health outcomes. Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network urologist.

You asked the Plan to pre-approve the out-of-network office visit. You say that this doctor played a crucial role in consulting in your care during the hospitalization. You say that it is urgent to continue follow up treatment and surgery with this doctor. The Plan denied your request. The Plan says the requested service is available within the network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 the office visit with an out-of-network urologist.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for the inpatient hospital care provided from October 21, 2020, through October 26, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment 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. Your contract with the Plan says that you must pay a $290 copayment per day, for days 1-5 and a $0 copayment for days 6-90, for inpatient hospital care. In some instances, readmission within 30 days may result in a continuation of benefits from the original admission, pending a quality medical review by the Plan. You have been asked to pay $1,450 ($290 copayment x 5 days) for the inpatient hospital care provided. Based on the Plan contract, however, readmission within 30 days may result in a continuation of benefits from the original submission. Your original admission to this hospital was from October 6, 2020, through October 8, 2020. The original argument of your appeal was not addressed by the Plan. Therefore, we decided that the Plan has to waive the copayment for the inpatient hospital care provided from October 21, 2020, through
October 26, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that the additional PT visits are medically necessary. The Plan denied your request. The Plan says the additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records you appear to have plateaued with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $270 to $150 for the shoulder arthroscopy surgery (29827) provided on January 15, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 a $270 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $270 copayment for the Medicare-covered surgery 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 adjust the copayment from $270 to $150 for the shoulder arthroscopy surgery (29827) provided on January 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre approve an additional 19 miles (A0170).

You asked the Plan to pre approve the additional 19 miles. You say that you recently moved and two of your
doctors are still in the previous location you moved from. The Plan denied your request. The Plan says your
benefit only allows for 50 miles in a one-way trip. The Plan also says that you have exceeded the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation, and each one-way trip must not exceed 50 miles of driving
distance.

We looked at your request, the records in the case file, and the rules. You are requesting an additional 19 miles
for a one-way trip, for a total of 69 miles. Your benefit only allows 50 miles in a one-way trip, and this request
exceeds the benefit limit. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre approve an
additional 19 miles (A0170).