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

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvecontinued services. The Plan denied your request. The Plan says you require supervision for all aspects of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.Continued SNF services beyond November 15, 2020, were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a standby assist to contact guard assist level with functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet 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 continued services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 22 additional physical therapy visits.
You asked the Plan to pre-approve 22 additional physical therapy visits. You say that the enrollee could benefit
further from additional skilled treatment. The Plan denied your request. The Plan says additional 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 22 additional physical 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 enrollee has had extensive therapy
for this condition and has been authorized to review an independent exercise program. Our reviewer says that
the unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 22 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 22 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 24, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency transportation
beyond the benefit limit of 12 one-way trips.
You asked the Plan to provide coverage for the additional non-emergency transportation. You say that you are
a new dialysis patient and need non-emergency transportation services three times a week, and you do not have
any family support. The Plan denied your request. The Plan says the benefit coverage cannot be provided for
additional non-emergent transportation above the limit of 12 one-way trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
We looked at your request, the records in the case file, and the rules. The file shows that your plan
transportation benefit provides coverage for 12 one-way non-emergency transportation trips. Therefore, we
decided that the Plan does not have to provide coverage for additional non-emergency transportation beyond
the benefit limit of 12 one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea left eye contact lens and fitting.You asked the Plan to pre-approvea contact lens and fitting. You say that the contact lenses are medically necessary.The Plan denied your request. The Plan says these services/items are not covered by Medicare or the Plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The Plan covers these services after cataract surgery.We looked at the file and the Plan's rules. Contact lenses are only covered after cataract surgery. Based on this information, we decided that the Plan's rules for coverage of a contact lens and fitting have not been met.Therefore, we decided that the Plan does not have to pre-approvea left eye contact lens and fitting.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on January 20, 2020.
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the enrollee previously received the same testing for the same primary cancer and the enrollee was not seeking further treatment for her diagnosis.
The Plan must follow Medicare rules. Medicare rules say that NGS tests such as Guardant360 are only covered under certain conditions, including that the enrollee has not previously been tested using the same NGS test for the same primary diagnosis of cancer. We looked at the file and Medicare rules. The enrollee was previously tested using the same NGS test for the same primary diagnosis of cancer. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on January 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qvar Redihaler.
You asked the Plan to pre-approve Qvar Redihaler. You say that the enrollee has tried albuterol, oral steroids
and oral antibiotics with no improvement. You say that the medication is necessary for their health and
symptoms. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by
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 Qvar Redihaler.
Benefits for Qvar Redihaler 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRocklatan eye drops.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plandenied your request. The Plan says that this is not covered under 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-approveRocklatan eye drops.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forth knee orthosis and suspension sleeve (L2397 and L1833) provide.
You asked the Plan to pay forth knee orthosis and suspension sleeve. You say that you would like reconsideration based on the records submitted.

The Plan denied your request. The Plan says two of more diagnosis codes on the claim are mismatched.The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Specifically, there is a more appropriate diagnosis code to represent bilateral osteoarthritis of the knee.
Therefore, we decided that the Plan does not have to pay forth knee orthosis and suspension sleeve (L2397 and L1833) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.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. The patient appears to be gradually improving, however, they require additional short-term acute care services of less than 25 days to further stabilize and complete treatment which can safely take place in the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service provided on January
1, 2020.
You asked the Plan to waive the copayment for ambulance service. You say that the services were medically
necessary. The Plan denied your request. The Plan says the cost share is correct.
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 $265
copayment for Ambulance services.
You have been asked to pay a $265 copayment for ambulance service. This service falls within the Ambulance
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 waive the copayment for the ambulance service
provided on January 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on August 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that this provider is out-of-network with the member's specific 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialist services provided on August 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the emergency care and Part B drugs you received from February 7, 2020, to February 10, 2020.
You asked the Plan to waive the cost share. You say that you cannot afford to pay this amount. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $75 copayment for Medicare-covered emergency care. Your contract also clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. Review of the file shows that you were provided emergency care and Part B drugs from February 7, 2020, to February 10, 2020. You have been asked to pay a $75 copayment for the emergency care and a 20% coinsurance for the drugs. 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 cost sharing for the emergency care and Part B drugs you received from February 7, 2020, to February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on June 5, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay fortheGuardant360 panel rendered on June 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMultaq tablets.You asked the Plan to pre-approveMultaq tablets. You say that the enrollee has been taking this medication for 3 years and has been covered by their insurance.The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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-approveMultaq tablets.Benefits for Multaq tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 15, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 15, 2020. The ambulance benefit is a transportation benefit.When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical repair provided on July 21, 2020.
You asked the Plan to waive the copayment for surgical repair. You say that you feel that you could have been
sutured in the same room you had the surgery in and feel that the provider was not upfront about the
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 $250
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay the allowed amount of $223.92, which is less than the $250 copayment for surgical
repair. Surgical repair 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 surgical repair provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says you do not have out-of-network 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 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 dental services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Epoetin Alfa injections you received
from June 6, 2018 to June 27, 2018.
You asked the Plan to waive the coinsurance for the Epoetin Alfa injections. You say that you don't agree with
this claim being reprocessed two years after the date of service. The Plan denied your request. The Plan says
you were charged this coinsurance 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 20%
coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Epoetin Alfa injections. The Epoetin Alfa injections falls
within the Medicare Part B drugs 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 coinsurance for
the Epoetin Alfa injections you received from June 6, 2018 to June 27, 2018.
Your complaint about the delay in the reprocessing of these claims 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: 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 stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
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 patient appears to be improving, however, they require additional short-term
acute care services of less than 25 days to further stabilize and complete treatment which can safely take place
in the current facility. The patient does not require services at the LTACH that are not already available at the
current facility. There are no services at the LTACH that the patient requires that are not already available and
covered at the current facility. Therefore, this request for LTACH services will be considered not medically
necessary at this time. Transfer to a lower level of care may be considered once treatment had completed.
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