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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that you lived alone prior to hospital admission and are in jeopardy of falling. You say that SNF care is medically necessary. The Plan denied your request. The Plan says SNF care is not medically necessary. The Plan says that the enrollee can safely receive the services needed in the current inpatient rehab setting.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a maximal assist for transfers. The enrollee required maximal assist with activities of daily living. The enrollee tolerated an oral diet. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Venofer infusions for the enrollee.
You asked the Plan to pre-approve a tier exception. You say that a cost exception is necessary for the enrollee.
The Plan denied your request. The Plan says tier exceptions are not allowed for Medicare Part B drugs.
Maximus overturned the Plans denial stating treatment with this drug was found to be necessary. The Plan
requested a reopen and stated that the request was not for coverage but for a cost share exception which is not
allowed.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. The enrollee's contract with the Plan clearly says that enrollees must pay 20%
coinsurance for Medicare Part B drugs. Tier exceptions are not permitted on this type of drug. This cost sharing
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the
Plan does not have to pre-approve a tier exception for Venofer infusions for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need more care than can be provided in a skilled nursing facility. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the 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 not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Kynmobi 10 mg sublingual film.
You asked the Plan to pre-approve Kynmobi. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested drug is not a Medicare Part B 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Kynmobi 10 mg sublingual film.
Benefits for Kynmobi 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third opinion consultation to be provided by an out-of-network provider.
You asked the Plan to pre-approve a third opinion consultation with an out-of-network provider. You say that you feel you did not get an unbiased second opinion and would rather go outside the Plan. The Plan denied your request. The Plan says they have providers in-network who can give you an opinion consultation.
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 a third opinion consultation to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950) provided on May 10, 2021.

You asked the Plan to pay for a core buildup. You say that you want the Plan to reconsider payment as you are diabetic and oral health is very important in your case. The Plan denied your request. The Plan says the service at issue 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core buildup (D2950) provided on May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the enrollee lives alone and has steps at his home. You say that the enrollee requires straight catheterization every 6 hours and is not able to do this on his own. You say that the enrollee is not voiding on his own. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of SNF care. The Plan says that the enrollee does not need daily skilled services in an inpatient setting.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was instructed on self-catheterization. The enrollee was at a standby assist level with functional mobility including gait to 50 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are identifiable skilled nursing and skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient acute care hospital stay provided on February 15, 2021, through February 26, 2021.
You asked the Plan to waive the copayment for the acute inpatient hospital care. You say that there should be no copayment applied to the inpatient stay due having COVID. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $190 copayment each day one through eight for inpatient hospital care. You have been asked to pay a $190 copayment each day one through eight for the acute inpatient hospital care. This service falls 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. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient acute care hospital stay provided on February 15, 2021, through February 26, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the established patient office or other outpatient visit (99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the established patient office or other outpatient visit. You say that this request is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to manage the enrollee's medical condition.

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 established patient office or other outpatient visit (99214) 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 the guided tissue regeneration - resorbable barrier, per site (D4266) the surgical placement of implant body: endosteal implant (D6010), the bone graft at time of implant placement (D6104), the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), the intraoral - periapical first radiographic image (D0220), the intraoral - periapical each additional radiographic image (D0230) received January 4, 2021.

You asked the Plan to pay for the dental services. You say that you think these services should be covered under your medical insurance and you are not seeking reimbursement for a dental claim from your dental insurance. The Plan denied your request. The Plan says the requested services are not covered under Original Medicare and are not covered under your supplemental benefit.

Medicare generally does not cover dental services. The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. Although Medicare does not cover dental services, 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 guided tissue regeneration - resorbable barrier, per site (D4266) the surgical placement of implant body: endosteal implant (D6010), the bone graft at time of implant placement (D6104), the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), the intraoral - periapical first radiographic image (D0220), the intraoral - periapical each additional radiographic image (D0230) received January 4, 2021.

Your complaint about the Plan not processing claims from 2020 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was no obtained for these services rendered by an OON 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 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 the laboratory services provided on February 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar facet injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of objective findings on physical exam of lumbar radiculopathy.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of a lumbar radiculopathy and there is no documentation of conservative therapies that have been trialed. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar facet injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and
would benefit from admission to an LTACH. The Plan denied your request. The Plan says an LTACH is not
medically necessary, however the Plan says they will most likely cover an acute rehab unit if desired to
continue appropriate treatment.

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. An LTACH is certified as an acute care hospital, and in general, LTACHs 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 they are currently receiving care. The documentation does not support that an additional 25
days of hospitalization are reasonably expected for the enrollee in this case, and the clinical assessment in the
case file does not support that the enrollee is reasonably expected to benefit from, and improve with , LTACH
services. Therefore, 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary, as you do not have the strength to use the manual wheelchair. The Plan denied your request. The Plan says the provider did not perform a mobility evaluation or prescribe a specific item.

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 the scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that you have a personal mobility deficit that significantly impairs the ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal that the mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker or wheelchair in the home. The documentation does not reveal that your home provides adequate access for the requested scooter, and the use of this scooter will significantly improve your mobility-related activities of daily living in the home. 

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
February 15, 2021, to March 16, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee's
benefit was exhausted.

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 July 17, 2020, to
February 14, 2020. The Plan has covered 100 days of SNF care.

We looked at the file and the rules. The Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 15, 2021, to March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the purchase and fitting of eyeglasses (V2025)
provided on September 9, 2020.
You asked the Plan to reimburse you for the purchase and fitting of eyeglasses. You say that you paid for
frames and lenses and are now seeking reimbursement. The Plan denied your request. The Plan says you
exhausted your $300 allowance for frames and lenses.
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 contract says that you have a $300 allowance once per year to use toward the purchase and
fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider.
We looked at the file and the Plan's rules. The records show you exhausted your $300 allowance for eyeglasses.
Based on this information, we decided that you are not eligible for additional reimbursement. Therefore, we
decided that the Plan does not have to reimburse you for the purchase and fitting of eyeglasses (V2025)
provided on September 9, 2020.
Your complaint about not receiving your eyeglasses is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.