Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit and observation stay provided from October 22, 2020, through October 26, 2020.
You asked the Plan to waive the copayment for the ER visit and observation stay. You say that there was a discrepancy in the billing so the hospital will be rebilling. You say that you are appealing the decision to deny medical coverage for the hospital stay. The Plan denied your request. The Plan says the ER copayment 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 $90 copayment for emergency services in an emergency room and $0 for outpatient hospital observation services. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you were admitted to outpatient observation, which was fully covered. Therefore, you are only responsible for the ER copayment. 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 the ER visit and observation stay provided from October 22, 2020, through October 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care following the elective reverse total shoulder arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says the inpatient hospital care is not necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care following the elective reverse total shoulder arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental placement of a semi-precision attachment (dental code D6192).
You asked the Plan to pre-approve dental service. You say that the enrollee needs this to stabilize his denture. The Plan denied your request. The Plan says this service is not covered by the Plan's dental 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 pre-approve dental placement of a semi-precision attachment (dental code D6192).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device.
You asked the Plan to pre-approve Vertiflex Superion device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have back pain. The Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the device. Therefore, you do not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the specialist office visits provided on June 30, 2020 and September 1, 2020.
You asked the Plan to reduce the copayments for the specialist office visits. You say that you requested prior authorization for the services to be covered at the in-network level. You say you should be charged for the in-network copayment because you only had one option. The Plan denied your request. The Plan says you have been asked to pay 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 $60 copayment for out-of-network specialist visit. You have been asked to pay a $60 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the prior authorization was approved for facility charges only. 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 reduce the copayments for the specialist office visits provided on June 30, 2020 and September 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thyroid imaging (78014).
You asked the Plan to pre-approve the thyroid imaging. You say that the thyroid uptake imaging is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the thyroid imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not contain Thyroid-stimulating hormone (TSH) testing results or any other evidence that the enrollee has subclinical hyperthyroidism. 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 thyroid imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve thyroid imaging (78014).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whole-body bone scan (78306).
You asked the Plan to pre-approve whole-body bone scan. You say that please reconsider determination of the enrollee's bone scan. You have to rule out bones vs liver in order to proceed with enrollee's health. The Plan denied your request. The Plan says the requested bone scan is not medically necessary.
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 whole body bone scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a full-body scan has the potential to identify disease in early stages, and early identification can improve the success of curative efforts. Controversy arises from the use of full-body scans in the screening of patients who have no signs or symptoms suggestive of a disease. As with any test that screens for disease, the risks of full-body CT scans need to be weighed against the benefit of identifying a treatable disease at an early stage. An alternative to a full-body CT scan may be MRI scans. MRI scans are generally more expensive than CT but do not expose the patient to ionizing radiation and are being evaluated for their potential value in screening. The review indicates that the items/services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of whole-body bone scan have not been met. Therefore, we decided that the Plan does not have to pre-approve whole-body bone scan (78306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system. You asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested accessory is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says the request is not indicated at this time.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT scan. Our physician reviewer found that the enrollee has a diagnosis of asthma, and is experiencing cough, dyspnea, and sinus congestion. The clinical notes do not provide a rationale for a chest CT. There are no abnormalities on examination of the chest. There is no hypoxemia at rest or with activity. The spirometry is normal. It would be reasonable to obtain a chest x-ray. If there are no abnormalities on chest x-ray, then no further chest imaging is indicated. If the chest x-ray is abnormal, chest CT may be indicated, depending on the findings. At this point, the requested chest CT is considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0800).
You asked the Plan to pre-approve a power wheelchair. You say that the power mobility device is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found the records do not support that the enrollee's condition cannot be ameliorated by a walker, cane or manual wheelchair. 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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0800).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport and ground mileage provided on October 10, 2020.
You asked the Plan to pay for the transportation services. You say that the claim denied because the enrollee was enrolled in hospice. You also say that that is incorrect because the enrollee's last day in hospice was October 1, 2020. 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 ambulance transport and ground mileage provided on October 10, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested admission 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 the documentation does support that the requested SNF coverage is medically reasonable and necessary. Our physician reviewer found the enrollee was independent with eating and upper body dressing. The enrollee required minimal assistance with lower body dressing. The enrollee was able to walk 60 feet times two with antalgic gait. The documentation supports that the enrollee has skilled therapy needs. The documentation supports that daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 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 Dermal wound cleanser.
You asked the Plan to pre-approve Dermal wound cleanser. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 Dermal wound cleanser.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray transportation (R0070).

You asked the Plan to pay for portable x-ray transportation. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing, and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part B.

We looked at the file and Medicare rules. The record shows that the service at issue was provided to a SNF resident. X-ray transportation is considered a technical component subject to consolidated billing and is not separately payable from the SNF stay. Based on this information, we decided that Medicare rules for coverage of portable x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray transportation (R0070).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physical therapy to be provided by the out-of-network provider. The Plan denied your request. The Plan says you 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from October 9, 2020, to November 7, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says continued stay was denied for ongoing skilled therapy because the enrollee had returned to his prior baseline level of function and did not have skilled nursing needs.
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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from October 9, 2020, to November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services to be performed by an out-of-network provider.
You asked the Plan to pre-approve the acupuncture services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this provider is out-of-network and the services are not urgent or emergent. The Plan states there are in-network providers that can provide the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the acupuncture services to be performed by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis Emulsion.
You asked the Plan to pre-approve the Restasis Emulsion. You say that you would like reconsideration because this drug is medically necessary to treat the member's condition. The Plan denied your request. The Plan says this drug is not covered under Medicare 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 Restasis Emulsion.
Benefits for the Restasis Emulsion may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.