Persius/hicric huggingface dataset:
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 enrollee needs therapy. The Plan denied your request. The Plan says the enrollee is inappropriate for discharge from the acute care facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care is not medically necessary and appropriate at this time. Our physician reviewer found from a nursing perspective, the beneficiary received IV medications. The beneficiary had stable vital signs. He was treated for worsening multifocal pneumonia and required suctioning and a nasopharyngeal airway. Regarding rehabilitation services, the beneficiary received physical therapy in the acute hospital. The beneficiary was unable to participate with physical therapy due to his evolving acute illness and dementia. The enrollee is acutely ill and not stable for transfer to a SNF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 6, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 6, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99213) provided April 16 to August 27,
2018.
You asked the Plan to pay for the physician services. You say that the claim was submitted timely. The Plan
denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the physician services was not filed until September 12, 2019. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for physician services (99213) provided April 16 to August 27, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for semi electric hospital bed (E0260) January 27, 2019 to June 29, 2019.
You asked the Plan to pay for semi electric hospital bed. You say that the enrollee is being charged $825 so you are appealing the denial of the bed lift as not being medically necessary. The Plan denied your request. The Plan says medical necessity has not been supported by the records.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 pay for semi electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically necessary for this patient. Our physician reviewer found The documentation does not support that the patient's condition requires positioning of the body in ways not feasible in an ordinary bed, frequent or immediate changes in body position, or special attachments that cannot be fixed and used on an ordinary bed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of semi electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for semi electric hospital bed (E0260) January 27, 2019 to June 29, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for a drug test provided on September 3, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that except for
emergency or urgent care, prior authorization from the Plan is required for services provided by out-of-network
providers.
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 has not provided us with the network status of the ordering provider.
Therefore, we decided that the Plan has to pay for a drug test provided on September 3, 2019.
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 waive the copayment for the specialist visit you had on August 15, 2019.
You asked the Plan to waive the copayment. You say that you did not see a doctor on this date. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $50 copayment for physician specialist services. Review of the file shows that you had a specialist visit on August 15, 2019. You have been asked to pay a $50 copayment for the services. The services fall within the physician specialist 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 specialist visit you had on August 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation beyond the closest available facility
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says ambulance transportation for miles beyond the closest facility is not covered.
The Plan must follow Medicare rules. Medicare rules say that ambulance services are covered only as far as the nearest appropriate facility. You are requesting admission and ambulance transfer from a hospital to a rehabilitation hospital. This is an ambulance trip of 210 miles. There are multiple appropriate facilities closer than this. 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 pre-approve ambulance transportation beyond the closest available facility
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is getting active wound care and physical therapy. The Plan denied your request. The Plan says skilled nursing and therapy does not need to be provided daily in an inpatient facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee reached her goals, and is at a modified independent level with functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures and tooth implants for the enrollee.

You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare or the plan.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dentures and tooth implants for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an enteral feeding supply kit (B4034) and formula (B4152) provided on June 16, 2019 through July 1, 2019.
You asked the Plan to pay for the enteral feeding supply kit and formula. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery for the billed items and units billed.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for an enteral feeding supply kit (B4034) and formula (B4152) provided on June 16, 2019 through July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on September 16,
2019.
You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says the
correct copayment was applied to the claim.
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 $50
copayment for vision care.
You have been asked to pay $50 copayment for the eye exam. The eye exam falls within the vision care benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for an eye exam provided on September 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the regadenoson injection, stress test and myocardial perfusion provided on August 5, 2019.
You asked the Plan to waive the cost share for the regadenoson injection, stress test and myocardial perfusion. You say that you were informed you would only have a $30 copayment. You say that you told the provider you did not want more tests if you would be charged more. 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 each Medicare-covered Part B drug, a $20 copayment for Medicare-covered non-radiological diagnostic services and $100 copayment for each Medicare-covered radiological diagnostic service.
You have been asked to pay a total of $166.18 for the regadenoson injection, stress test and myocardial perfusion.
Service
Allowed Amount
Standard Cost Share
Member Liability
Regadenoson Injection
$230.09
20%
$46.18
Stress Test
$53.69
$20
$20
Myocardial Perfusion
$338.63
$100
$100
TOTAL:
$166.18
The regadenoson injection falls within the "Medicare Part B Prescription Drugs" benefit category. The stress test and myocardial perfusion fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 share for the regadenoson injection, stress test and myocardial perfusion provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99202) to be provided by an out of network
provider.
You asked the Plan to pre-approve an office visit. You say that you have been going to this provider for thirty
years and he is familiar with you. You tried to go to other podiatrists and you have to go more often because
they don't know your situation as well as the provider. The Plan denied your request. The Plan says you may
get services from out-of-network providers when providers of specialized services are not available in-network.
For services to be covered from an out-of-network provider, your in-network provider must request prior
authorization from the Plan. The prior authorization request will be reviewed program staff that are trained to
understand the specialist's area of expertise. If the service is not available within your plan's network, your
request will be approved. There may be certain limitations to the approval, such as just one initial consultation
visit or a specified type or amount of services. If the specialist's services are available within your plan's
network, the request for services outside the network may be denied.
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 pre-approved care.
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
an office visit (99202) to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve the out-of-network office consultation. You say that you need cervical disc replacement and would like a second opinion. The Plan denied your request. The Plan says the record does not show that care is required by an out-of-network provider and there are providers in-network that can render this service.
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 pre-approved care. 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 medical services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics (L3216, L3002). You say that you have bilateral foot pain and prefer shoes that have an orthopedic arch support. The Plan denied your request. The Plan says you were approved for diabetic shoes and inserts and the requested orthotics are not a covered benefit because you do not wear a covered leg brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for a total of 12 visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 additional physical therapy 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 you have low back pains, sciatic in nature, as well as right hip pains. As of October 31, 2019, you have completed at least 32 visits of physical therapy. Physical therapy has resulted in less pain and stiffness and treatments have included modalities, strengthening, and home exercise program implementation. There is no indication that residual deficits could not be addressed via a home exercise program, given completion of a reasonable amount of physical therapy to date. Therefore, you do not meet criteria for the requested additional physical therapy visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits for a total of 12 visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral upper eyelid blepharoplasty.
You asked the Plan to pre-approve bilateral upper eyelid blepharoplasty. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that blepharoplasty is covered when the above criteria are met. 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 bilateral upper eyelid blepharoplasty. Our reviewer says that bilateral upper eyelid blepharoplasty is not medically reasonable and necessary. Our physician reviewer found that history and physical on October 22, 2019, did not elucidate any vision complaints. Physical examination documented visual acuity of 20/20 for both eyes, but without physical exam findings. Automated visual field tests on October 22, 2019, showed normal superior visual field for both eyes. Repeat testing with "taped" eyelids was not provided. Photographs demonstrated bilateral upper eyelid dermatochalasis. Diagnosis was bilateral upper eyelid blepharochalasis. Medicare criteria were not met for upper eyelid blepharoplasty based the lack of superior visual field loss upon visual field testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral upper eyelid blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral upper eyelid blepharoplasty.