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

We decided that the Plan does not have to pay for deluxe frames (V2025), progressive (V2781) and prism lenses (V2715) provided on August 17, 2018.You asked the Plan to pay for the eyewear. You say that you do not think you should have to pay anything because your explanation of benefits shows zero member cost sharing.The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received you also received deluxe frames, progressive and prism lenses which were not covered, and will be considered as upgrades to the standard benefit. You signed a waiver at the time of purchase. You agreed that you would be responsible for these charges. 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 pay for deluxe frames (V2025), progressive (V2781) and prism lenses (V2715) provided on August 17, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on July 2, 2019.You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for 95941 because this code is not recognized by Medicare Advantage Plans.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 95941 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, CPT code 95941 has a status code of I. This means that 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on July 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are medically necessary.The Plandenied 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 above.We asked our physicianreviewer 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with dizziness and lower extremity weakness and encephalopathy. She was found to have a urinary tract infection as well as elevated blood pressure. She is ambulating 80 feet with a walker and modified assist. She needs maximum assist for toilet transfers and modified assist for bed to chair, sit to stand, and lying to sit. She does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-one (J7326).You asked the Plan to pre-approveGel-one. You say that the requested medication is necessary.The Plan denied your request. The Plan saysbased on the documentation provided, coverage criteria for a step therapy exception has 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 topre-approve Gel-one. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects forthe enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-one have not been met.Therefore, we decided that the Plan does not have to pre-approveGel-one (J7326).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forsurgical services (CPT 22325) provided to the enrollee on February 6, 2018.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysprocedure code 22325-AS-59 is not supported by the medical records submitted.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 22325 is "Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; lumbar."We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the operative note indicates that the enrollee's diagnosis was spondylolisthesis, but the bill was submitted with a diagnosis of spondylolysis. Furthermore, assuming spondylolisthesis was present, this degenerative dislocation is not considered a traumatic fracture or dislocation, which is what CPT 22325 is intended to indicate. Therefore, the billing of CPT 22325 is not supported.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forsurgical services (CPT 22325) provided to the enrollee on February 6, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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 LTACH services are covered if theyare 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia, influenza and acute respiratory distress syndrome (ARDS). The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator to a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that after participating in a half marathon you began to feel dizzy and sat down. A local paramedic helped you to an ambulance where they tested your vitals and evaluated you. You say that you declined transportation to the hospital because you thought that the services would not be covered since you were out of area. You said that you were told you would not be billed for the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 6, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe urgent care visit provided on November 19, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 you must pay a $45 copayment for each Medicare-covered in -and out-of-service area urgent care provider visit. You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the each "Urgently needed 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 forthe urgent care visit provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 16, 2019 through September 18, 2019.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you are not able to pay the copayment because you have a lot of expenses already. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you were admitted on September 16, 2019 and discharged on September 18, 2019. You were asked to pay a $325 copayment per day from September 16, 2019 through September 17, 2019, days 1-2 of your inpatient hospital care. You were discharged on September 18, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-5. 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 inpatient hospital care from September 16, 2019 through September 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProcrit for the enrollee.You asked the Plan to pre-approveProcrit. You say that Procrit is medically necessary for the enrollee.The Plan denied your request. The Plan says based on the medical records provided it is unknown if Procrit/Epogen is being used to reduce transfusion (the transfer of blood/blood components from one person into the bloodstream of another person)-related risks. The Plan says it is unknown if the enrollee's iron stores are adequate (ferritin level of at least 100 ng/ml and transferrin saturation of at least 20%) within the last 30 days. The Plan states that if the iron tests of the enrollee's blood are not supportive or available, then supplemental iron must be used in combination. The Plan states that the records do not show the enrollee's hemoglobin (test of the red blood cells) is less than 10 g/dL within the last 30 days.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.Medicare also has specific coverage criteria for Procrit. Based on the Medical records provided, the required criteria for Procrit arenot met at this time. The records are incomplete and do not show all required coverage criteria are met. Therefore, we decided that the Plan does not have to pre-approveProcrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the power mobility device purchased on August 19, 2019.
You asked the Plan to reimburse you for the scooter. You say that you bought the scooter so you can breathe when you do a lot of walking. The Plan denied your request. The Plan says criteria was not met and the supplier is not a Medicare certified supplier, therefore no payment can be made.
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 . This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the power mobility device purchased on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 forthe medical services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on October 28, 2019.You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says services by non-participating providers are excluded.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 service 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 radiology services provided on October 28, 2019.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Prolia for enrollee.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says that 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 medically necessary. Our physician reviewer found the enrollee has post-menopausal osteoporosis and is at high risk of fracture. It is documented that the enrollee has a new onset of vertebral compression fracture, which is considered an osteoporosis-related fracture. The records do not show that the enrollee has tried and failed the plan's required drugs of oral bisphosphonates and zoledronic acid; however, the record indicates that oral bisphosphonates and zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The Prolia is therefore reasonable and medically necessary at this time.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 been met.Therefore, we decided that the Plan has to pre-approve Prolia for enrollee. 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 found to be medically reasonable and necessary for you. Our physician reviewer found you had therapy and medical needs that met criteria for acute level rehabilitation. Care at a lower level would not have effectively met your rehabilitation needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of IRF care have been met.Therefore, we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 13, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.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 forthe medical services provided on June 13, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on October 9, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the 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 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 a drug test provided on October 9, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 physical therapy services.
You asked the Plan to pre-approve the 12 physical therapy services. You say that the enrollee has declined in function due to chemotherapy treatment for bladder carcinoma. The Plan denied your request. The Plan says the physical therapy 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 the 12 physical therapy services. 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 the enrollee has been working on strength, endurance, stretching and sequencing to improve independence with sliding board transfers with no significant changes. Our physical reviewer found that the requested services do not require the skills of a licensed therapist and that a caregiver can provide the services as part of a home program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 12 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 physical therapy services.