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

We decided that the Plan does not have to pay for bifocal eyeglass lens (V2202) and eyeglass frames (V2020) purchased on November 5, 2019.You asked the Plan to pay for the eyeglasses frames and lenses. You say that in 2017 and 2018 you filled your eyeglass prescription outside of the network and was given the $150 allowance. Your benefits have not changed and you should be granted the $150 allowance.The Plan denied your request. The Plan says enrollee's must receive vision services from a network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a plan optical facility. We looked at the file and the Plan's rules. Services received from an out-of-network provider will not be covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses frames and lenses have not been met.Therefore, we decided that the Plan does not have to pay for bifocal eyeglass lens (V2202) and eyeglass frames (V2020) purchased on November 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.You asked the Plan to pre-approve the SNF services.The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF care.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 the SNF services. Our reviewer says that dailyskilled services are notmedicallynecessary. Our physician reviewer found that from a nursing perspective, you received oral and inhaled medications. You had stable vital signs and you were treated for pneumonia. You were alert with confusion and able tofollow one-step commands. Regarding rehabilitation services, you received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the acute hospital. You were at a maximal assist of two for functional mobility and you were non-ambulatory. You required varying assist with activities of daily life. You tolerated a ground diet and thin liquids.Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled therapy service needs; however, skilled nursing or skilled therapy services (or a combination of these services), is not medically necessary on a "daily basis" in aSNF.  As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetriamcinolone acetonide (Zilretta).You asked the Plan to pre-approveZilretta. The Plan denied your request. The Plan says 32mg given as a second course of treatment is more than the maximum allowed dose for the enrollee's indication.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Zilretta. Our physician reviewer found that the enrollee has bilateral osteoarthritis of her knees. She received Zilretta, along acting preparation into her knees with good effect. The request is for a second set of injections. The efficacy and safety of repeat administration have not been demonstrated. Therefore, the request is considered not medically reasonable or 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 Zilretta have not been met.Therefore, we decided that the Plan does not have to pre-approvetriamcinolone acetonide (Zilretta)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee is with a past medical history of atrial fibrillation, Parkinsonism, prior stroke and chronic inflammatory demyelinating polyneuropathy who presented to the acute hospital on 01/22/2020 with respiratory distress. He experienced respiratory failure and was intubated and treated for Coronavirus infection and pneumonia with nebulizer treatments and antibiotics. He required placement of a tracheostomy tube due to failure to wean from the ventilator. He was very weak in the hospital and evaluated by neurology who ultimately felt the enrollee had signs and symptoms consistent with amyotrophic lateral sclerosis. He received treatment with intravenous immunoglobulin, steroids and plasmapheresis. He is being fed via a feeding tube. His condition largely remained unimproved and he was reportedly transferred to a skilled nursing facility on 03/19/2020. An additional report from 03/21/2020 reports the patient is now back at home and no additional services are requested. Based on the provided medical records the acute care hospital was able to provide all of the services the enrollee required. Based on the provided medical records it is not clear what additional services the LTACH would provide that the skilled nursing facility is unable to provide. Based on the provided medical records there is no indication that the enrollee is not able to receive appropriate services in the skilled nursing facility. No additional records are available with regard to the latest report that the enrollee is now back at home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device. 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. 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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physician services (99214, 99354 and 99355) provided on December 31, 2018. You asked the Plan to waive the coinsurance for the physician services. You say that you would like reconsideration as you should not be liable for these services. The Plan denied your request. The Plan says the correct liability has been applied to this 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 a 50% coinsurance for out-of-network Physician/Practitioner Services.
You have been asked to pay $51.30 for medical services. The allowed amount is $102.60. 50% of $102.60 is $51.30
You have been asked to pay $62.92 for medical services. The allowed amount is $125.83. 50% of $125.83 is $62.92.
You have been asked to pay $47.59 for medical services. The allowed amount is $95.18. 50% of $95.18 is $47.59.
You have been asked to pay a 50% coinsurance for out-of-network for the physician services. The physician services fall within the Physician/Practitioner 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 coinsurance for physician services (99214, 99354 and 99355) provided on December 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on August 12, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says minor pain procedures under most routine circumstances do not require anesthesia.
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 01992 is anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position. We find that CPT code 01992 is not supported in the medical record. In this case, there were insufficient records provided to show that anesthesia services were medically reasonable and necessary for the nerve block/injection provided to the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 12, 2019.You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed services were not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the medical record. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or specific treatment strategy. There are no medical records that clearly document the physician's intent for the test to be performed. This testing is not covered for screening purposes. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on May 31, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 services was not filed until June 7, 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 the services provided to the enrollee on May 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthopedic knee consultation provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an orthopedic knee consultation. You say that you would like this claim reprocessed and approved for payment. 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 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 has network providers available who can provide 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 orthopedic knee consultation provided on October 10, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that you need SNF rehab due to a severe infection and suffering from a stroke. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF care.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective, you received enteral medications and nutrition. You had stable vital signs and you were treated for C. difficile infection. Regarding rehabilitation services, you received physical therapy (PT) in the acute hospital. You were at a maximal to total assist for functional mobility and was non-ambulatory. Our physician reviewer found that there are identifiable skilled nursing service needs. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) is not medically necessary on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis in a skilled nursing facility setting. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient clinic visit (G0463) provided October 31, 2019.
You asked the Plan to waive the deductible for the clinic visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the correct cost sharing was applied. 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 there is a $150 deductible for Outpatient Hospital Services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Hospital Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible for Outpatient Hospital Services. This cost sharing is a contractual obligation that had not been met at the time the clinic visit was received on October 31, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient clinic visit (G0463) provided October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for presumptive and definitive drug testing provided to the enrollee on April 1, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the place where the sample was taken is reported as the Place of Service (POS).
We find that the CPT codes are not supported in the medical record. Specifically, the records do not show that the sample at issue was taken at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for presumptive and definitive drug testing provided to the enrollee on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on July 10, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered to the enrollee on July 10, 2019.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) scan provided on October 19, 2019.
You asked the Plan to pay for the imaging services. You say that the service provided to the enrollee is not related to the hospice diagnosis code. The Plan denied your request. The Plan says that 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 must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide documentation that would substantiate the dates the enrollee was enrolled in hospice. Without the documentation to show this we cannot confirm that the services should have been billed to Original Medicare. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scan provided on October 19, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from August 31, 2019 to September 6, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges because you met the MOOP amount for the year. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 the MOOP amount for 2019 is $5,700. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs from August 31, 2019 to September 6, 2019. The record shows that you had only paid $5,017.90 toward the $5,700 MOOP amount prior to receiving services. Therefore, you are responsible to pay $682.10, which is less than the 20% coinsurance amount. You have been asked to pay $682.10 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from August 31, 2019 to September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that it is too difficult to take your daughter up the stairs. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.