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

We decided that the Plan does not have to pre-approve Humira for the enrollee.
You asked the Plan to pre-approve Humira. The Plan denied your request. The Plan says that this is not covered when supplied by a pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Humira for the enrollee.
Benefits for Humira 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 an office visit (99203) and strapping an ankle and/or a foot (29540) provided on June 25, 2019 by out of network provider
You asked the Plan to pay for an office visit and strapping an ankle and/or a foot. You say that you disagree with the Plan's determination and the response received fails to provide a detailed rationale for this action. The Plan denied your request. The Plan says they denied the payment of the medical services listed because the service was not authorized by the member's primary care physician (PCP). The Plan also says that all health services other than emergency services or urgently needed services received outside the plan service area must be authorized by the member's PCP.
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 an office visit (99203) and strapping an ankle and/or a foot (29540) provided on June 25, 2019 by out of network provider,
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee admitted to the
acute inpatient setting on 12/22/2019 for the treatment of pneumonia. He was deemed medically stable and
discharged to home with daughter and home care on 01/02/2020, where he remains at the time of this appeal.
The enrollee's prior level of function was independent in home environment. Physical therapy (PT) and
Occupational therapy (OT) hospital notes the enrollee ambulated 250 feet with a rolling walker and stand by
assist. The enrollee requires verbal cues to slow down. For sit to stand functioning, the enrollee was moderately
independent. For stand to sit functioning the enrollee needed stand by assistance and requires 24/7 supervision.
A progress note dated 01/01/2020, notes Rocephin and Azithromycin were changed to Augmentin and the
enrollee was to continue taking Mucinex. Dysphagia likely due to infectious process in the setting of mild
dementia and advanced age. The enrollee was on a regular diet with thin liquids.
The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that
the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may
benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive
rehabilitation facility therapy program level 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 two gingival irrigations, surgical placement of implant body: endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown.
You asked the Plan to pre-approve the gingival irrigations, endosteal implant, abutment, and abutment supported porcelain/ceramic crown. You say that these services are a medical necessity because you have pain with your top teeth because enamel is gone and chipping, and fillings are ready to fall out. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 two gingival irrigations, surgical placement of implant body: endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from July 26, 2019 to July 31, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you are appealing this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $275 copayment per day for days 1-6 for each Medicare covered hospital stays.
You have been asked to pay a $275 copayment per day for days 1-5 of the inpatient hospital care. ($375 x 5 = $1,375). The inpatient hospital care falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 26, 2019 to July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the podiatry visit provided on September 17, 2019.
You asked the Plan to reduce the copayment for the podiatry visit. You say that that a $30 copayment is too much for a nail clipping. You say the plan only pays $14.63 and you feel that is what you should be paying. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 copayment in a specialty physician's office. You have been asked to pay a $30 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The medical record shows you received nail debridement 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 reduce the copayment for the podiatry visit provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on August 8, 2019.
You asked the Plan to pay for the dental service. You say that you were referred to this provider to examine and perhaps biopsy a lesion on your tongue. The Plan denied your request. The Plan says the incisional biopsy of oral tissue is not listed as a covered service.
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 incisional biopsy of oral tissue is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forpower wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT Code K0822) purchased from a non-contracted provider on March 27, 2019.You asked the Plan to pay forthe power wheelchair. You say that you feel the Plan should reimburse you as you have out-of-network benefits available under the Plan and that the wheelchair is medically necessary as you are a double amputee.The Plan denied your request. The Plan says you did not get prior approval for the power wheelchair.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. Your EOC clearly states, prior authorization (approval in advance) may be required. Furthermore, you don't need to get a referral orprior authorization when you get care from out-of-network providers. However, before getting services from out-of-network providers you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. This is important because without a pre-visit coverage decision, if the Plan later determines that the services are not covered or were not medically necessary, the Plan may deny coverage and you will be responsible for the entire cost.Therefore, we decided that the Plan does not have to pay forpower wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT Code K0822) purchased from a non-contracted provider on March 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Lumigan 0.01% eye drops.
You asked the Plan to pre-approve the eye drops. You say that it is medically necessary that you get this medication and request consideration. The Plan denied your request. The Plan says this item is limited to Medicare Part B covered drugs.
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 the Lumigan 0.01% eye drops.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram on September 24, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that your mammogram should be considered preventive. The Plan denied your request. The Plan says the claim was reprocessed to pay with a $10 copayment.
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 $10 copayment for each basic imaging service (e.g., general x-rays or ultrasounds). You have been asked to pay a $10 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows a history of breast cancer. Therefore, the mammogram is diagnostic in nature.
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 mammogram provided on September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the continuation of SNF care does not meet criteria.
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. 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 continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to SNF on 1/3/20 due to decreased strength and mobility for one week (low sodium levels). At issue is continued SNF admission after 1/16/20. Her prior level of function was living alone in an apartment and her sister performed cleaning, cooking, and shopping. She was independent with mobility and activities of daily living. Her current level of function is ambulating 150 feet with a wheeled walker with contact guard assist, standby/contact guard assist with balance, contact guard assist with transfers and bed mobility, contact guard assist with toileting, Set-up/contact guard assist with dressing, and supervision with bathing. Based on available records, the enrollee does not meet criteria for coverage of continued SNF after 1-16-20. The records do not support that the enrollee needs continued daily physical therapy and occupational therapy (PT and OT). There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing PT and OT, the records do not support the need for daily therapy.
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 continuation of skilled nursing facility (SNF) care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the strapping of unna boot provided on August 28, 2019.
You asked the Plan to pay for the strapping of unna boot. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 29580 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the strapping of unna boot have not been met.
Therefore, we decided that the Plan does not have to pay for the strapping of unna boot provided on August 28,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe transportation services.You asked the Plan to pre-approvethe transportation services. You say that your new prosthetic leg does not allow you to easily enter and exit your personal vehicle, making the requested transportation necessary. You say that you do not want to risk falling and injuring yourself.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 non-emergent transportation provided by wheelchair vans, taxis, stretcher vans, or ambulettes. The services you have asked the Plan to pre-approve are non-emergent transport services.Therefore, we decided that the Plan does not have to pre-approvethe transportation services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis provided to the enrollee on August 13, 2019.
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 is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 77061 is "Diagnostic digital breast tomosynthesis; unilateral." We find that CPT code 77061 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 diagnostic digital breast tomosynthesis provided to the enrollee on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foam rubber mattress (E0272) sales tax (S9999)
adjustable frame (A9270) provided on July 4, 2019 to July 8, 2019.
You asked the Plan to pre-approve the foam rubber mattress and adjustable frame. You say that you were not
able to get a bed that you were able to sleep on for your back and him from a provider. The Plan denied your
request. The Plan says these items are not covered under the plan benefits. Enrollee's must receive their DME
supplies from an in-network provider.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. Medicare rules say that plans can require enrollees to get care from network providers.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. 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.
Therefore, we decided that the Plan does not have to pre-approve foam rubber mattress (E0272) sales tax
(S9999) adjustable frame (A9270) provided on July 4, 2019 to July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 6, 2019 to October 25, 2019.
You asked the Plan to pay for the diabetic supplies. You say that The Plan denied your request. The Plan says that there is no valid proof of delivery.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 6, 2019 to October 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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. 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted for acute care on 01/09/2020 with acute hypoxemic respiratory failure. He was treated with intravenous steroids and received nebulizer treatments. The enrollee lives with his spouse in a single level apartment without steps to the entrance and had been at a modified independent level with bed mobility using an adjustable bed and was able to perform a stand pivot transfer to a wheelchair. As of 01/13/2020 he required minimal assistance when transitioning from supine to seated. He was able to transfer from seated to standing and ambulate 100 feet x 3 with a rolling walker and contact-guard assistance. The enrollee is status post acute care admission with treatment for respiratory failure as described above. The enrollee requires oversight of his medical conditions and medication management. He is at risk for further episodes of respiratory failure. The enrollee requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) for tooth # 12 provided on
October 8, 2019.
You asked the Plan to pay for the dental service. You say that you do not believe that you have exceeded the
annual limit. The Plan denied your request. The Plan says that 2 extractions per calendar year are covered. The
Plan says the frequency limit has been exceeded.
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 and extractions are a covered service,
the frequency limit has been reached. The record shows that you last received 2 extractions for teeth # 32 and
29 on April 4, 2019. Therefore, we decided that the Plan does not have to pay for the surgical extraction
(D7210) for tooth # 12 provided on October 8, 2019.