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

We decided that the Plan does not have to waive the deductible for the ultrasounds provided on November 2, 2020.
You asked the Plan to waive the deductible for the ultrasounds. You say that the ultrasounds were ordered to check for lymphoma and an aneurysm, which are prudent measures. You say that the decision should be reconsidered. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to radiological diagnostic services. This cost sharing is a contractual obligation that had not been met at the time the ultrasounds were received on November 2, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasounds provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain provided on September 24, 2020 by an OON provider.
You asked the Plan to pay for the emergency treatment of dental pain. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that this service is not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain provided on September 24, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copay for the eye exam provided on August 20, 2020.
You asked the Plan to waive the copay for the provided exam. The Plan denied your request.
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 $40 copay for vision care. The Plan says you must pay a $50 copay for the provided exam. Based on the Plan contract, however, you cannot be asked to pay more than a $40 copay for the exam. Therefore, we decided that the Plan has to reduce the copay for the eye exam provided on August 20, 2020.
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 acute inpatient rehabilitation facility (IRF) admission and services.
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 your needs can safely be met 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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from November 2, 2020, to November 11, 2020.
You asked the Plan to waive the copay for the services provided. You say that you received poor treatment. The Plan denied your request. The Plan says the copay 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 $295 copay per day for days 1-6 for inpatient hospital care. You have been asked to pay a $295 copay for the services provided. The services fall 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 copay for the inpatient hospital services provided from November 2, 2020, to November 11, 2020.
Your complaint about being treated poorly 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (codes D2392 and D2393) provided on December 8, 2020.

You asked the Plan to pay for the resin-based composites. You say that you were assured by several Plan representatives that your necessary dental work would be covered.The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that you called regarding extractions and participating providers only, and no requests for information regarding fillings was requested.

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, restorations are limited to two procedures per calendar year. The record shows that you received two resin-based composites on October 20, 2020, and your restorations benefit had been exhausted.Therefore, we decided that the Plan does not have to pay for the two resin-based composites (codes D2392 and D2393) provided on December 8, 2020.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital with a fall, traumatic scalp laceration, mastoid fracture, subdural hemorrhage, and acute respiratory failure requiring mechanical ventilation support. The course was also complicated with occipital stroke and new onset atrial fibrillation. The enrollee appears to be unstable at this time, requiring additional short-term acute care services to stabilize, which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on June 26, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was rendered by a non-participating 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 surgical services provided to the enrollee on June 26, 2020.
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records show you do not have skilled needs which can only be provided on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computerized tomography (CT) cryoablation of the lung.
You asked the Plan to pre-approve a CT cryoablation of the lung. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT cryoablation of the lung. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical literature does not contain sufficient evidence supporting the use of cryoablation of the lung for suspected recurrence of lung cancer, and it has not been demonstrated that this therapy is at least as effective as existing medically appropriate alternatives. In addition, it has not been definitively determined that the enrollee in this case has recurrent cancer. 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 CT cryoablation of the lung have not been met. Therefore, we decided that the Plan does not have to pre-approve a computerized tomography (CT) cryoablation of the lung.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.

You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria have not been met.

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. The Plan covers 48 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve proton beam radiation therapy (77387, 77525, G6002, 77523).
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that proton beam therapy will be considered as medically reasonable and necessary for malignant lesions of the prostate as long as the criteria listed in the LCD 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 proton beam radiation therapy. Our reviewer says that the criteria for coverage of proton beam radiation therapy have been met. Our physician reviewer found the comparison of treatment plans provided shows that the proton-based plan results in reduced normal tissue exposure and that the intensity-modulated radiation therapy plan does not achieve accepted dosimetric constraints while the proton-based plan does. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam radiation therapy (77387, 77525, G6002, 77523).
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided on September 13, 2020.
You asked the Plan to pay for the ultrasound. You say that the enrollee's hospice eligibility shows that the enrollee was only active on hospice until September 11, 2020. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee ended Medicare Hospice benefits on September 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ultrasound provided on September 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.You asked the Plan to pre-approve Monovisc. 

You say that these services are medically necessary.The Plan denied your request. The Plan says that the use of Monovisc would be appropriate only if Monovisc specifically has been tried and failed or if you were unable to tolerate Orthovisc, Synvisc, and/or Synvisc-One.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Monovisc. Our reviewer says that Monovisc is not medically reasonable and necessary. The provided records did not show that you have tried and failed Orthovisc or Synvisc-One. Orthovisc or Synvisc-One would not be significantly different in their effectiveness or safety compared to the requested drug based on current evidence. Our physician reviewer found that your condition does not meet step therapy criteria for Monovisc.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met.Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 7, 2020.

You asked the Plan to waive the copayment for urgent care visit. You say that the urgent care did not do anything and you should not have a copay obligation. The Plan denied your request. The Plan says the copayment amount you are being charged 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 $65 copayment for each urgent care visit. 

You have been asked to pay $65 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on July 7, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has 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 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 found to be medically reasonable and necessary for this enrollee. The complexity of the patient's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a complex medical history with multiple conditions that would benefit from an acute inpatient admission with close physician supervision. He would benefit from multiple therapies including physical therapy and occupational therapy and this would likely be best if offered 15 hours over seven consecutive days. The patient has participated in therapy and made progress and there is 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 meets 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

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.