Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance forthe inpatient services provided from May 11, 2020, to May 19, 2020.You asked the Plan to adjust the coinsurance forthe inpatient services. You say that you were admitted on May 14, 2020 so your coinsurance should be less.The Plan denied your request. The Plan says preadmission services are included in the inpatient payment therefore there is no increase to your coinsurance based on 8 days instead of 5 days.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay 10% coinsurance for Inpatient Hospital Care. You have been asked to pay 10% coinsurance for the inpatient services. The inpatient services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Medicare and the Plan pay the hospital a predetermined amountbased on the diagnosis related group payment system, including preadmission services. Therefore, we decided that the Plan does not have to adjust the coinsurance forthe inpatient services provided from May 11, 2020, to May 19, 2020
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin injections provided on June 19, 2020, and June 
20, 2020. 
 
You asked the Plan to pay for the insulin injections. You say that the insulin and other medications were 
administered by nurses. The Plan denied your request. The Plan says insulin injections are not covered by Part 
B. The Plan also says that insulin injections are self-administered drugs. 
 
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 pay for the insulin injections provided 
on June 19, 2020, and June 20, 2020.  
 
Benefits for the insulin injections 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens (V2781) and polycarbonate lens (V2784) provided on July 10, 2020.
You asked the Plan to pay for the progressive lens and polycarbonate lens. You say that you were not aware that some lenses are not covered. The Plan denied your request. The Plan says certain enhancements are not covered through the Plan's supplemental routine vision allowance. 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 under certain specific scenarios but does not cover certain enhancements. We looked at the file and the Plan's rules. The progressive lens and polycarbonate lens you purchased are specific enhancements that the Plan does not cover under any scenario. You did receive a reduced charge for these enhancements but according to the Plan's rules, these services are never covered. Based on this information, we decided that the Plan's rules for coverage of the progressive lens and polycarbonate lens have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens (V2781) and polycarbonate lens (V2784) provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment of Varicose veins.
You asked the Plan to pre-approve treatment of Varicose veins. You say that the requested treatment of the enrollee's varicose veins is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a covered indication for the requested treatment of Varicose veins.
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 treatment of Varicose veins. Our reviewer says that the enrollee does not have a covered indication for the requested treatment of Varicose veins. Our physician reviewer found based on the documentation provided, there is no evidence of activity limiting symptoms that persist despite conservative efforts. There is no documentation of a concerted effort at conservative therapy. The assessment provided was performed only one month after a diagnosis of DVT in the leg in question. This is an insufficient window to separate out the DVT symptoms from superficial reflux. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatment of Varicose veins have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment of Varicose veins.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approverental of a CPAPmachine.You asked the Plan to pre-approvethe DME. You say that the DME is necessary.The Plan denied your request. The Plan says Medicare defines CPAP compliance as use for at least four (4) hours/night at least 70% of the time. The Plan statesaccording to the information they received from the provider did not meet this criteria.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 requestto pre-approve the DME. Our physician reviewer found the criteria for continued coverage of CPAP are not met.  This patient was diagnosed with severe OSA in June 2020, and prescribed CPAP. The compliance summary July to August did not meet minimum criteria for use. The patient has had another sleep study, and prescription for CPAP, but there are no new compliance data. The insurer contacted the patient by phone but he declined to be contacted further about CPAP. The CPAP is considered not medically necessary because it is not being used, and the denial is upheld.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 DMEhave not been met.Therefore, we decided that the Plan does not have to pre-approverental of a CPAP machine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on October 29, 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 the claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plandoes not have to pay forthe Guardant360 panel rendered on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One injection services. 
 
You asked the Plan to pre-approve the Gel-One injection services. You say that the enrollee has osteoarthritis 
as well as a complex tear of the meniscus, which is causing severe pain. The Plan denied your request. The 
Plan says the Part B Step Therapy criteria have 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 looked at the file and Medicare rules. The case file did not contain valid medical records. The Plan 
 provided evidence of having made reasonable attempts to obtain medical records. You have not submitted 
information which confirms that Medicare criteria have been met for an exception to step therapy. There are no 
records showing that the enrollee has tried the required drugs of Synvisc, Durolane, and Gelsyn-3. There are no 
records showing that these drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Based on this information, we decided that Medicare rules for coverage of the Gel-One injection 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One 
injection services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia injections (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary for your condition. The 
Plan denied your request. The Plan says you have not met the required criteria for coverage of Prolia. 
 
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 Prolia. Our reviewer says that you have 
not met the required step therapy requirements for coverage of Prolia. Our physician reviewer found the review 
has determined that the Plan requires a trial of drug, Zoledronic Acid, before they will approve the requested 
drug if the enrollee does not have a history of osteoporotic fracture. In this case, the patient has not tried and 
failed the required drug. The enrollee does not have a history of an osteoporotic fracture. There is no 
documentation provided indicating that the Plan?s required drug would likely be less effective and/or likely 
have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia injections (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the closure of salivary fistula and two extractions provided 
on May 28, 2020. 
 
You asked the Plan to pay for the closure of salivary fistula and extractions. The Plan denied your request. The 
Plan says these services are not covered benefits under your plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the closure of salivary fistula and 
two extractions provided on May 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan 0.02%-0.005% eye drops. 
 
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Rocklatan 0.02%-0.005% 
eye drops.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's doctors recommend therapy in an IRF.The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee's current medical status does not require intensive physician or nursing supervision in an IRF. Our physician reviewer also found that the enrollee may benefit from multiple therapies, but the documentation does not support that he requires or can tolerate this at an IRF level of intensity.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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forfacet joint injections provided on May 20, 2020, and June 10, 2020.You asked the Plan to waive the copayments forfacet joint injections. You say that you were told that the copayments would be waived due to COVID-19.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 $350 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.You received a facet joint injection on May 20, 2020. A face joint injection is an outpatient surgical procedure and is subject to cost-sharing charges during COVID-19. Therefore, you are responsible to pay the $350 copayment.  You received afacet joint injection on June 10, 2020. A face joint injection is an outpatient surgical procedure and is subject to cost-sharing charges during COVID-19. Therefore, you are responsible to pay the $350 copayment.  The total amount you owe is: $700. You have been asked to pay the total copayment amount of $700for facet joint injections. Facet joint injections fallwithin the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 forfacet joint injections provided on May 20, 2020, and June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
You asked the Plan to pre-approve Venofer. You say that you want to be treated with this drug. The Plan 
denied your request. The Plan says the laboratory values were not supplied therefore they were unable to 
determine if this medication is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Venofer. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found the lab results do not indicate the enrollee is 
iron deficient. The submitted information indicates the enrollee received the drug on October 3, 2020 which 
could influence the results. The submitted documentation does not support that the drug is reasonable and 
necessary, nor that it is safe and effective 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 Venofer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Venofer.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 29, 2020, to 
June 30, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 5, 2020, 
to June 28, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from June 29, 2020, to June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on July 3, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was 
provided due to a dental emergency. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) and is limited to one procedure per plan year. The record shows that you received a 
problem focused limited oral evaluation (D0140) on June 25, 2020, and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on July 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99348) provided on June 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 the home visit (99348) provided on June 10, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on July 14, 2020. 
 
You asked the Plan to pay for the ambulance 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 July 14, 2020. 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 for the ambulance services provided by you on July 
14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on March 17, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that payment was recouped in error. You say 
that the recoupment did not include a detailed explanation in reference to the enrollee's policy or applicable 
regulations for the reason why the plan recouped payment. The Plan denied your request. The Plan says 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 also says it 
is the provider's responsibility to verify the member's coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia services provided on March 17, 2020.