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

We decided that the Plan does not have to pre-approve a knee orthosis.

You asked the Plan to pre-approve a knee orthosis. You say that you have no cartilage in your knee and cannot walk due to the issue. The Plan denied your request. The Plan says that your request is not medically necessary because you do not have objective evidence of instability in the medical records.

The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered if the LCD 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 knee orthosis. Our reviewer says that a knee orthosis is not considered medically reasonable and necessary in this case. There is no evidence of objective instability on a physical exam of the knees. There is no pathological laxity with objective measurements of any laxity of the knee. There is no evidence of a recent surgery or injury to the knee. Our physician reviewer found that your condition does not meet Medicare criteria for a knee orthosis. 

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96374) provided November 1, 2020 to November 3, 2020.

You asked the Plan to waive the copayment for the injection services. You say that if you would have known that you would be charged $325 per day you would either have not gone ahead with the treatments or insisted on being treated as an inpatient. The Plan denied your request. The Plan says the claim was processed with the correct copayments applied per the Evidence of Coverage.

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 $325 copayment for surgery or other services provided at an outpatient hospital including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $641.19 ($213.73 x 3 days) for the injection services. Since the allowed amount is less than the copayment amount, you are responsible for the lesser amount. The injection services fall within 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 copayment for therapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96374) provided November 1, 2020 to November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.

You asked the Plan to pay for IRF care. You say that you are in the hospital and you are unable to walk. Your
healthcare providers and family members feel it is important for you to get acute inpatient rehabilitation to
benefit your overall health and restore your previous level of function. The Plan denied your request. The Plan
says criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be
provided at a lower level of care.

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 pay for 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 complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 23, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that the frequency was exceeded because you needed to find a new, network dentist who had to perform a comprehensive oral evaluation. The Plan denied your request. The Plan says the requested service has a frequency limitation of 36 months. You last received this service in August of 2020.

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 only covered under this benefit once every 36 months. The Plan has stated that the requested service was last covered on August 21, 2020. Your benefit was exhausted when you received this service on February 23, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for 10 additional occupational therapy visits.

You asked the Plan to pre-approve for 10 additional occupational therapy visits. You say that the requested occupational therapy visits being requested are necessary in order to safely return home. The Plan denied your request. The Plan says the clinical information provided do not show that the ongoing skills of an occupational therapist are needed.

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 for 10 additional occupational therapy 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 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 extensive therapy 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, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program and can self-propel a manual wheelchair. The requested services are not 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 patient'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 10 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve for 10 additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the surgical extraction. We decided that the Plan does not have to pay for the problem focused limited oral evaluation.

You asked the Plan to pay for the problem focused limited oral evaluation and surgical extraction. You say that you did not enter into any private contract with the treating provider. You also say that the contractual obligation to pay this claim is owed to you as a covered beneficiary. The Plan says that these services are not allowed because they were performed by a provider who has chosen to opt out of Medicare.

We decided that the Plan has to pay for the surgical extraction.

The Plan must follow Medicare rules. The rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.

The record shows that you received a surgical extraction from a Medicare opt out provider. The EOC includes surgical extraction as a covered benefit. The EOC does not clearly state that dental services rendered by a Medicare opt out provider are not covered, nor does it reference that surgical extractions are not covered. You reasonably believed this service would be covered, as it is listed as a covered benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical extraction have been met. Therefore, we decided that the Plan has to pay for the surgical extraction.

We also decided that the Plan does not have to pay for the problem focused limited oral evaluation.

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, exams, including periodic oral exam and emergency diagnostic exam, are limited to two procedures per calendar year. The record shows that you received a periodic oral evaluation on February 5, 2020, and a problem focused limited oral evaluation on February 18, 2020, and your exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation.

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 Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this request is
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle
Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 11, 2021 by an out of network provider.
You asked the Plan to pay for the office visit. You say that this claim was billed according to Telehealth guidelines. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 11, 2021 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible, proximal to splenic flexure (45378) provided January 27, 2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that you went to the hospital to get the colonoscopy done. You paid your $40 copay and you got a COVID test which was required for the colonoscopy. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $200 copayment for ambulatory surgery.

You have been asked to pay $200 copayment for the colonoscopy. The colonoscopy falls within the Outpatient surgery, including 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 copayment for the colonoscopy, flexible, proximal to splenic flexure (45378) provided January 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional occupational (OT) visits.

You asked the Plan to pre-approve additional OT visits. You say that the additional OT is medically necessary.
The Plan denied your request. The Plan says five (5) additional OT visits are not medically necessary. The Plan
must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve five (5) additional OT 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 therapy 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
beyond what the health Plan approved. The requested services are not 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 five (5) additional OT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve five (5) additional OT visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the repair of scalp wounds (12031) and the benign lesion excision (11401) provided on August 25, 2020.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the services provided.

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 an annual deductible of $750. This is the amount you have to pay out of pocket before the Plan will pay their share for your covered medical services. 

You have been asked to pay a $322.28 deductible applied for the physician surgical services provided as you had not previously met the yearly deductible of $750. 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 deductible for the repair of scalp wounds (12031) and the benign lesion excision (11401) provided on August 25, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for an eye injection provided on January 22, 2021.
You asked the Plan to waive the copayment for the eye injection. You say that you receive the shots in your doctor's office suite, and it should be covered. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for per visit for all covered services. The Plan says you must pay a $150 copayment for the eye injection. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the eye injection. The Explanation of Benefits (EOB) shows the provider was the physician, not the facility. The record shows there are mismatching claim numbers. This means we cannot determine if the EOB and the claim form are for the same claim. Therefore, we decided that the Plan has to waive the copayment for the eye injection provided by on January 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires physical,
occupational and speech therapies to maintain his strength and abilities. The enrollee requires daily wound care
and evaluation. An LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee's
records indicate that the full course of care has not been completed in the hospital. An LTACH does not
provide a clinical advantage over a non-LTACH acute care hospital. Therefore, transfer to an LTACH facility
is not medically necessary. Once the enrollee is ready to leave the hospital, they will need continued care,
including skilled nursing and therapy. These services can be safely provided in another setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently receiving acute hospital care, and acute care services have
not been denied. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general
do not provide clinical services that are materially different than those of short-term acute care hospitals. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services.
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pay for the pneumatic compression device and sleeves. You say that this was medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan follows Medicare rules. The rules state that a Pneumatic Compression Device (PCD) coded as E0675 to treat peripheral arterial disease (PAD) is not eligible for reimbursement We looked at the file and Medicare rules. Specifically, this item is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise class (S9451) provided January 1, 2021.

You asked the Plan to pay for the exercise class. You say that you would like the class to be reimbursed. The Plan denied your request. The Plan says reimbursement was issued for 2021 but adequate proof of payment has not been submitted for 2021 and therefore reimbursement cannot be approved.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only up to $150 per calendar year when you submit a Wellness Allowance reimbursement form along with proof of payment. 

The Plan's rules for coverage of gym benefits have not been met because the Plan has not received documentation showing what you have paid for the exercise class in 2021. Therefore, we decided that the Plan does not have to pay for the exercise class (S9451) provided January 1, 2021.