Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefits for the Chronically Ill SSBCI).
You asked the Plan to pre-approve the SSBCI benefit. You say that your provider is waiting for the plan to her regarding her health condition to validate if you qualify supplementary benefits. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefits for the Chronically Ill (SSBCI) for 2021.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefits for the Chronically Ill SSBCI).
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 documentation shows clinical support for LTACH care. 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on January 11, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with these charges. You say that you already paid this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $45 copayment for physician/practitioner services/specialist. You have been asked to pay a $45 copayment for a specialist office visit. The correct copayment has been applied to the office visit that was provided by a specialist. A specialist office visit falls within the physician/practitioner services/specialist 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 office visit provided by a participating provider on January 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips.
You asked the Plan to pre-approve twenty (20) additional routine transportation trips. You say that you require transportation. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
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 a maximum of sixty (60) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of sixty (60) trips for routine transportation. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Trilogy and Life 2000 ventilator system.
You asked the Plan to pre-approve the Trilogy and Life 2000 ventilator system. You say that you would like reconsideration because the member has failed other modalities of treatment. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested Life2000 system.
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 Trilogy and Life 2000 ventilator system. Our reviewer says that a home ventilator is considered not medically necessary. This member has idiopathic pulmonary fibrosis. The pulmonary function tests do not support a diagnosis of COPD. There are no diagnoses of thoracic restrictive disease or neuromuscular disease. There is no documentation of CO2 retention on an arterial blood gas done while the patient is stable. Our physician reviewer found the Life2000 system is not medically necessary. This system is not a true ventilator. There is not sufficient evidence of efficacy or safety in the treatment of pulmonary fibrosis. 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 Trilogy and Life 2000 ventilator system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Trilogy and Life 2000 ventilator system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Austedo.

You asked the Plan to pre-approve Austedo. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Austedo.

Benefits for Austedo 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 pay for the office visit provided on December 14, 2020, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says authorization was not requested for the non-emergent office visit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 14, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on March 6, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 for the anesthesia services rendered on March 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased on January 13, 2021.

You asked the Plan to pay for the eyeglasses purchased from an out-of-network provider. You say that you are entitled to a pair of new eyeglasses and need to be reimbursed for the amount allowed. The Plan denied your request. The Plan says the allowed fee for the eyeglasses was applied toward your out-of-network deductible.

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 there is a $500 deductible for out-of-network medical services. 

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for covered out-of-network medical services. This cost sharing is a contractual obligation that had not been met at the time eyeglasses were purchased from an out-of-network provider on January 13, 2021. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99070, 96372) provided to the enrollee on October 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment.

We looked at the file and Medicare rules. Code 99070 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 99070. Additionally, procedure code 96372 is part of an edit pair with procedure code 96360. Procedure code 96360 is a column one code, and procedure code 96372 is a column two code. Procedure code 96360 has been billed on this date of service, which means that procedure code 96372 is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99070, 96372) provided to the enrollee on October 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 9, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 service 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 physician services provided to the enrollee on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the hospital outpatient clinic visit (G0463) provided on February 10, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $750 annual deductible. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services.

You have been asked to pay $47.50 for the deductible applied for the hospital outpatient clinic visit provided as you had not previously met the required annual deductible indicated in the Plan contract. This is the Plan's allowed amount for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible for the hospital outpatient clinic visit (G0463) provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 12, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no records 
from the ordering provider documenting the treating physician had intended the clinical diagnostic test be 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on March 12, 2021.
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 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. 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 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). You say that you suffer chronic
Hypertension, which is being treated by your primary care physician. The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back orthosis provided on April 8, 2021.

You asked the Plan to pay for the orthosis. You say that all telemedicine modalities including voice is allowed. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. There are insufficient medical records to substantiate the back orthosis. The records do not include any previous physical exams, testing, or imaging to confirm a diagnosis or condition. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the back orthosis provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture (D5214).

You asked the Plan to pre-approve the lower partial denture (D5214). You say that you did not know the provider doesn't belong to the Plan and you want the decision reversed. The Plan denied your request. The Plan says the service 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 the lower partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerumen removal rendered on October 10, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 5 represents codes that are payable only when performed in the inpatient or outpatient hospital setting.

We looked at the file and Medicare rules. The file shows that the claim was billed with place of service 23 for an emergency room. Payment for these services is not made for this place of service. Therefore, we decided that the Plan does not have to pay for the cerumen removal rendered on October 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional home health physical therapy visits.
You asked the Plan to pre-approve the additional home health physical therapy visits. You say that you would
like reconsideration because the requested therapy is medically necessary. The Plan denied your request. The
Plan says the member should be able to transition to a home education program with the total approved visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional home health physical
therapy visits. Our reviewer says that based on the medical records provided, there is no documentation that
that skilled therapy services are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the
enrollee's level of function and/or prevent deterioration beyond the 23 visits already approved by the Health
Plan. Our physician reviewer found the documentation does not clearly indicate why the 23 approved visits are
inadequate to meet the enrollee's care needs.
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 additional home health physical therapy visits have not been met. Therefore,
we decided that the Plan does not have to pre-approve the additional home health physical therapy visits.