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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing or therapy 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric inpatient hospital services beginning on November 12, 2020.
You asked the Plan to pay for psychiatric inpatient hospital care. You say that due to circumstances outside the hospitals control, you were unable to request prior authorization for these services. These services should be covered as medical necessity was met. The Plan denied your request. The Plan says this enrollee was admitted to the hospital following a court order where they were found incompetent to stand trial. Medicare does not pay for services furnished to individuals who have been committed under a penal statute.
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for services furnished without charge to individuals who have been committed under a penal statute. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychiatric inpatient hospital care have not been met, specifically, this enrollee was admitted to the hospital by a penal statute. Therefore, we decided that the Plan does not have to pay for psychiatric inpatient hospital services beginning on November 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visits (99337) provided from March 25, 2021 to April 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OON domiciliary or rest home visits. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 domiciliary or rest home visits (99337) provided
from March 25, 2021 to April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites, crowns, and core buildup, including any pins when required provided on March 9, 2021 by an OON provider.
You asked the Plan to pay for the resin-based composites, crowns, and core buildup. You say that you were told that your dentist was in-network with this Plan, and you feel the services should be covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the resin-based composites, crowns, and core buildup, including any pins when required provided on March 9, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided on December 17, 2020.
You asked the Plan to pay for the office visit. You say that you were in Alabama and went to the chiropractor. You want to use your out of state benefits for the chiropractic visits. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor. only manual manipulation of the spine to correct subluxation is covered. All other services provided in a chiropractor's office are not covered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care. The Plan must follow Medicare rules. The rules say that the only chiropractic service
Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99202) provided on December 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One injection services.
You asked the Plan to pre-approve the Synvisc One injection service. You say that the enrollee has chronic bilateral knee pain which is refractory to Intra articular steroid injections, NSAIDs, analgesics, topical rubs, weight loss, and exercise. You say that a right knee MRI revealed multiple abnormalities, mainly cartilage degeneration. You say that a trial of Synvisc One is highly recommended. The Plan denied your request. The Plan says Synvisc One is not a preferred medication. The Plan says that there are no clinical studies showing that this requested injection is more efficacious or safer than the preferred formulary alternatives.
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 the Synvisc One injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates the enrollee has bilateral knee osteoarthritis. The record indicates that the requested drug is a new start. The record does not indicate the enrollee has tried and failed the plan's preferred step one alternatives or that those agents are medically not appropriate for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Synvisc One injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One injection services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on January 6, 2021, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the psychotherapy services at issue were rendered to the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 services at issue in this appeal. 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 the psychotherapy services (90832) provided on January 6, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient services provided on March 13, 2021.
You asked the Plan to waive the coinsurance for the outpatient services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient services provided in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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% coinsurance for Outpatient hospital services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient services provided in an outpatient hospital facility on March 13, 2021. You have been asked to pay a 20% coinsurance for the outpatient services, totaling $27.22. The outpatient services fall within the Outpatient
hospital 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 the outpatient services provided on March 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiopulmonary resuscitation (92950-51) provided on December 5, 2020.
You asked the Plan to pay for cardiopulmonary resuscitation. You say that this was billed correctly. The Plan
denied your request. The Plan says this was billed with an inappropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that in the Physician Fee Schedule, a Multiple
Procedure (Modifier 51) indicator of 0 indicates that no payment adjustment rules for multiple procedures
apply.
We looked at the file and Medicare rules. The billed code, 92950, has a Multiple Procedure (Modifier 51)
indicator of 0, meaning modifier 51 is not appropriate. Based on this information, we decided that Medicare
rules for coverage of cardiopulmonary resuscitation have not been met. Therefore, we decided that the Plan
does not have to pay for cardiopulmonary resuscitation (92950-51) provided on December 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus shot provided on March 8, 2021.
You asked the Plan to pay for a tetanus shot. You say that this was administered due to an injury. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus shot. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus shot. Therefore, we decided that the Plan does not have to pay for a tetanus shot provided on March 8, 2021.
Benefits for a tetanus shot may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) supplies rendered on February 26, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you no longer use the equipment. The Plan denied your request. The Plan says the coinsurance was 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 a 20% coinsurance for durable medical equipment and related supplies.
Review of the file shows that you received CPAP supplies on February 26, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the durable medical equipment and related 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 coinsurance for the continuous positive airway pressure (CPAP) supplies rendered on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve a CPAP device. You say that this request is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules state that CPAP therapy when used in adult patients with OSA is considered reasonable and necessary under enumerated conditions 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 a CPAP device. Our reviewer says that
a CPAP device is medically reasonable and necessary. Our physician reviewer found that in this case, the
record indicates that the enrollee has sleep apnea. The provided records indicate that the enrollee underwent
supervised sleep testing. The record indicates that the AHI is 29. The elements of the coverage criteria are
satisfied. The requested service is recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CPAP device have been met. Therefore, we decided that the Plan has to preapprove
a continuous positive airway pressure (CPAP) device.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prosthesis.
You asked the Plan to pre-approve addition, endoskeletal system, high activity knee control frame (L5930). You say that the enrollee will have the ability to ambulate on uneven terrain and allow him to move forward with his life. The Plan denied your request. The Plan says the vendor states the enrollee is not a high impact user and there is no reason why the enrollee needs a computerized knee instead of a mechanical knee.
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 addition, endoskeletal system, high activity knee control frame (L5930). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the high activity knee control frame (L5930) is medically reasonable and necessary. A high activity knee control frame (L5930) is covered for beneficiaries whose functional level is 4. Based on the medical records provided the enrollee's functional level is a 3. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of addition, endoskeletal system, high activity knee control frame (L5930) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this enrollee has a complex medical history and would benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the records do not indicate that this enrollee requires an intensive therapy program with multiple visits from a rehab doctor each week. The necessary care can safely be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the enrollee is generally medically stable with progressive debility and no recent neurological or orthopedic events, and there is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week or need for acute rehab nursing care. While the enrollee may benefit from physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee's medical problems are not new, and their current level of function does not require an IRF admission. An IRF admission is not medically necessary based on the current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulators (TENS) unit.

You asked the Plan to pre-approve a TENS unit. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a TENS unit is covered for the treatment of beneficiaries with chronic, intractable pain or acute post-operative pain when specific coverage 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 a TENS unit. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not have acute post-operative pain or chronic pain other than low back pain with a qualifying presumed etiology. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulators (TENS) unit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided on January 1, 2021, to January 29, 2021.

You asked the Plan to waive the copayment for SNF care. You say that the services were medically necessary, and you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $0 copayment, for days 1-20, and a $184 per day, for days 21-100 for SNF care.

You have been asked to pay a $184 copayment per day, for SNF care. The records show that you were originally admitted to the SNF on December 17, 2020, to January 29, 2021 for a total of forty-four (44) days. You are covered for SNF care with a $0 copayment for days 1-20. You were not charged a copayment for your first twenty (20) days. The $184 copayment is assessed from day 21-65 assessing you twenty-four (24) days of care for a total cost-share of $4,416 ($184 x 24 days = $4,416). 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 skilled nursing facility (SNF) care provided on January 1, 2021, to January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, removal of impacted tooth and consultation provided on April 5, 2021.

You asked the Plan to pay for the extraction, removal of impacted tooth and consultation. You say that the dental customer service gave you this dental practice as a preferred in-network provider. The Plan denied your request. The Plan says dental services with an out-of-network provider are not 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, removal of impacted tooth and consultation provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nexlizet for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexlizet for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.