Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile, non-impregnated gauze (A6219) provided on November 4, 2020, by an out-of-network provider.

You asked the Plan to pay for sterile gauze. You say that the requested item was a medical necessity for 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 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 sterile, non-impregnated gauze (A6219) provided on November 4, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and tooth extraction to be performed by an oral surgeon.

You asked the Plan to pre-approve a consultation and tooth extraction to be performed by an oral surgeon. 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.

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. The Plan states covered services must be performed by a participating general dentist.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a consultation and tooth extraction to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation and tooth extraction to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and limited oral evaluation provided on April 6, 2021.

You asked the Plan to pay for the panoramic x-ray and limited oral evaluation. You say that the doctor needs to see how each tooth root is shaped in order to pull your last few teeth. You say that this is a new procedure, with a new dentist, in a new year and the decision should be re-evaluated. The Plan denied your request. The Plan says the panoramic x-ray is only covered once every 5 years and the limited oral evaluation is not a covered benefit.

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, the panoramic x-ray is only covered once every five years. The plan paid for a panoramic x-ray provided on October 6, 2020, which exhausted your benefit. The limited oral evaluation is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and limited oral evaluation provided on April 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 18, 2021, through February 28, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on February 17, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for SNF services
provided from February 18, 2021, through February 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on July 25, 2019.

You asked the Plan to pay for the home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely.

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 home visit was not filed until October 27, 2020. 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 home visit provided on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced leg pump to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an advanced leg pump to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.

Therefore, we decided that the Plan does not have to pre-approve an advanced leg pump to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a fitting for bifocal spectacles (92341) provided on March 5, 2021.

You asked the Plan to pay for a fitting for bifocals. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit.

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 does not cover these services. 

We looked at the file and the Plan's rules. A fitting for bifocal spectacles is not a covered benefit of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of a fitting for bifocals have not been met. Therefore, we decided that the Plan does not have to pay for a fitting for bifocal spectacles (92341) provided on March 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care, from June 23, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 you no longer qualified for SNF coverage after June 22, 2021. You did not have documented skilled nursing needs. You did not have documented skilled therapy needs, having reached an independent level of function. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of your condition. You apparently had a new medical issue requiring hospital evaluation in the evening of June 22, 2021, has no bearing on the issuance of the Notice of Medicare Non-Coverage (NOMNC) on June 17, 2021. Furthermore, the outcome of the hospital evaluation is unknown and, therefore, provides no basis for ongoing SNF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care, from June 23, 2021, forward.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) skilled nursing visits (CPT code G0299 X8), for the enrollee.

You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your request. The Plan says there are no new reports in any clinical changes in the enrollee's condition which require skilled nursing to revisit. The Plan states the enrollee has family to assist the enrollee with their medications and to monitor their needs. The Plan states this information does not support the need for a skilled nurse to make home visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 visits. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (advanced wound care, new ostomy care/teaching, frequent medication changes/teaching). Isolated lab draws are not in-and-of themselves considered a skilled service. As such, the requested home health registered nurse services are not shown to be medically necessary or reasonable. 

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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) skilled nursing visits (CPT code G0299 X8), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound and a specialist visit provided on December 30, 2020, and January 19, 2021.

You asked the Plan to waive the copayments for an ultrasound and a specialist visit. You say that you disagree with the charges because you pay $200 a month and should not owe anything more. 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 you must pay a $45 copayment for X-rays. Your contract with the Plan also clearly says that you must pay a $35 copayment for specialist visits. 

You received an ultrasound on December 30, 2020. Therefore, you are responsible to pay the $45 copayment. 

You had a specialist visit on January 19, 2021. Therefore, you are responsible to pay the $35 copayment.

The total amount you owe is: $80. 

You have been asked to pay the total copayment amount of $80 for an ultrasound and a specialist visit. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 copayments for an ultrasound and a specialist visit provided on December 30, 2020, and January 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) homecare skilled nursing visits.

You asked the Plan to pre-approve the visits. You say that you would like to have your home health aide, occupational therapy, physical therapy, and skilled nursing extended to provide care for your medical needs, as it is important to your health. The Plan denied your request. The Plan says the requested skilled nursing visits are not reasonable and necessary in your clinical scenario.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 visits. Our physician reviewer found the health plan's denial should be upheld. You do not have documented skilled nursing needs. You have a small wound, which is receiving simple wound care. There is no evidence of frequent medicine changes. There is no evidence of a new ostomy device. You have involved family and paid caregivers, who appear able and willing to tend to your needs. As such, the requested, ongoing, home health services are not shown to be medically necessary or reasonable. 

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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) homecare skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 15, 2021.

You asked the Plan to pay for foot orthotics. You say that the enrollee has been diagnosed with plantar fasciitis. The Plan denied your request. The Plan says this item is not a covered benefit.

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 suffer from diabetic foot disease and 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 pay for foot orthotics provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this request is still being studied for the treatment of chronic knee pain after total knee
arthroplasty.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested genicular nerve ablation of the knee is not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed body member. Currently there are
no higher quality studies or trials demonstrating long-term efficacy and possible adverse effects.

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 Plan does not
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) and drugs or medicaments dispensed in the office for home use (D9630) provided February 17, 2021.

You asked the Plan to pay for the oral cancer screening and take-home medications. You say that you would like the claims paid. The Plan denied your request. The Plan says these services are not covered under your benefits.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) and drugs or medicaments dispensed in the office for home use (D9630) provided February 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior extensive outpatient therapy visits and the records do not demonstrate that the
unique skills of a professional therapist are required to safely and effectively provide treatment, that the
services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the
supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program.
The requested services are not required as part of a maintenance program, are the specialized skill, knowledge
and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture, one or more needles; without electrical stimulation (97811) for treatment of thumb pain.
You asked the Plan to pre-approve the acupuncture services. You say that you have had acupuncture treatment in the past for other issues and it has worked for you in the past. You would like to approve the request for acupuncture on your thumb to ease the pain you are having and to avoid surgery. The Plan denied your request. The Plan says the requested service is not considered medically necessary.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the plan only covers acupuncture for manual manipulation of the spine to correct subluxation. You are requesting acupuncture on your thumb which is not covered. Therefore, we decided that the Plan does not have to pre-approve the acupuncture, one or more needles; without electrical stimulation (97811) for treatment of thumb pain.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from July 30, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 

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 continuation of SNF care from July 30, 2021, forward.