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

We decided that the Plan does not have to pre-approve a group 2 pressure-reducing support surface (E0277).

You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says there are no pressure ulcers, wounds, or a myocutaneous flap.

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 mattress. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the presence of multiple stage 2 pressure ulcers located on the trunk or pelvis, or a myocutaneous flap or skin graft. The documentation does not show a failure to improve in the previous month with conservative treatment. 

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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 pressure-reducing support surface (E0277).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 20, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reprocessed and paid. The Plan denied your request. The Plan says these services were rendered by a non-participating provider, and the enrollee was referred by another non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 subsequent nursing facility care provided on October 20, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on October 28, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the claim was submitted with timely filing. The
Plan denied your request. The Plan says the services could have been performed in 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the pathology services provided on October 28, 2019 by an out of network
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 29, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 subsequent nursing facility care provided on May 29, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for radiation therapy services provided on November 16, 2020, December 2, 2020, December 7, 2020 and December 9, 2020. We also decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on December 11, 2020 and December 14, 2020.
You asked the Plan to waive the coinsurance for radiation therapy services and office visit. You say that you believed there wouldn't be any significant out-of-pocket expenses. You say that the charges seem excessive. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to waive the coinsurance for radiation therapy services provided on November 16, 2020, December 2, 2020, December 7, 2020 and December 9, 2020.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit complete claim screens or explanation of benefits showing the coinsurance applied for these dates of service. This means that we cannot determine the coinsurance amounts you are being asked to pay for these dates are correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the coinsurance for radiation therapy services provided on November 16, 2020, December 2, 2020, December 7, 2020 and December 9, 2020.
We also decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on December 11, 2020 and December 14, 2020.
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 20% coinsurance for radiation therapy services.
Date of service
Service
Allowed Amount
Coinsurance
Member Liability
December 11, 2020
Radiation Therapy
$423.12
20%
$84.62
December 14, 2020
Radiation Therapy
$65.18
20%
$13.04
TOTAL:
$97.66
Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the FDA approval criteria for use of the device is not 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided while you were in the hospital November 2, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these drugs are covered under the pharmacy benefit, not the medical 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 pay for the self-administered drugs provided while you were in the hospital November 2, 2020.
Benefits for the self-administered drugs 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation SNF services from October 25, 2020, through November 23, 2020.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the care rendered was custodial.
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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee no longer qualified for SNF coverage after October 24, 2020. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long-term 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services from October 25, 2020, through
November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 17,
2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you were told that because the
visit was a follow-up you would not owe a copayment. 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 $15
copayment for each specialist visit.

You had a specialist visit on February 17, 2021. Follow-up visits are subject to cost-sharing charges. Therefore,
you are responsible to pay the $15 copayment.

You have been asked to pay a $15 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist visit provided on February 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reimburse the copayment for an X-ray provided on January 7, 2020.
You asked the Plan to reimburse the copayment for an X-ray. You say that you disagree with the charges because the Plan required the testing. 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 $100 copayment for basic radiological services provided at an outpatient hospital facility. You received an X-ray at an outpatient hospital facility on January 7, 2020. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 reimburse the copayment for an X-ray provided on January 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for physical therapy services provided from July 15, 2020, to February 9, 2021.

You asked the Plan to adjust the copayment for physical therapy services. You say that you should only have a $10 copayment for in network services. The Plan denied your request. The Plan says you were charged the copayments 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 $40 copayment for Outpatient Rehabilitation services.

You have been asked to pay a $40 copayment for each physical therapy visit. Physical therapy services fall within the Outpatient Rehabilitation services 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 adjust the copayment for physical therapy services provided from July 15, 2020, to February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2331) for tooth # 27, and a filling (D2392) for tooth # 28 provided on January 27, 2021.
You asked the Plan to pay for the dental services. You say that you were told that you were not aware that these services would not be covered. You say that had you known you would have to pay out of pocket, you would not have had these services done. The Plan denied your request. The Plan says fillings are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2331) for tooth # 27, and a filling (D2392) for tooth # 28 provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated shoulder orthosis provided to the enrollee on September 17, 2020.

You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code.

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 pay for the orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a physical examination of the shoulder. 

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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a prefabricated shoulder orthosis provided to the enrollee on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3346).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 pre-approve dental services (D3346).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for syncope and pacemeker placement. The enrollee's medical conditions are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by a chiropractor on February 15, 2021.

You asked the Plan to pay for the office visit. You say that this was an initial visit to the chiropractor and is the same as subsequent visits that have been covered. The Plan denied your request. The Plan says the claim was billed as an office visit and chiropractic office visits are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided by a chiropractor on February 15, 2021.
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 the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria must be be met for this monitor to be approved.

The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered is there is frequent (four or more times per day) blood glucose testing.

The file shows that you are not testing blood glucose four or more times per day. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0935).

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 

You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0935).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
February 1, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be
covered. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per
period.

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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on January 25, 2019 and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on February 1, 2021.