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

We decided that the Plan does not have to pay for continuation of SNF services provided from June 20, 2020,
through July 20, 2020.
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The
Plan denied your request. The Plan says Medicare criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, it is my opinion that the enrollee no longer qualified for SNF coverage. The enrollee
did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy
needs. The enrollee was consistently ambulating more 100 feet. He was otherwise limited by his dementia.
Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the
enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be
provided at a lower level of care (ex. home, assisted living, long term care).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for continuation of SNF services provided from June 20, 2020, through July 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 5, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this physician has opted out of the Medicare program.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. Therefore, we decided that the Plan does not have to pay for physician services provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orgovyx 120mg tablets.
You asked the Plan to pre-approve Orgovyx. You say that Orgovyx is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B Medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Orgovyx 120mg tablets
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the allowance benefit for progressive lenses provided on February 9, 2021.
You asked the Plan to pay more than the allowance benefit for the progressive lenses. The Plan denied your request. The Plan says the claim processed with the correct $100 eyewear benefit allowance. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct $100 eyewear benefit allowance. Therefore, we decided that the Plan does not have to pay more than the allowance benefit for progressive lenses provided on February 9, 2021.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance the echocardiogram. We decided that the Plan does not
have to waive the coinsurance the echocardiogram.
You asked the Plan to waive the coinsurance the echocardiogram. You say that you should not be responsible
for this amount because the service was medically necessary. The Plan says that you have been asked to pay
the correct cost-sharing amount.
We decided that the Plan has to reduce the coinsurance the echocardiogram.
The Explanation of Benefit shows that the allowed amount for the echocardiogram is $920. ($920 x 20% =
$184).
The Plan says that you must pay $920 for the echocardiogram. Based on the plan contract, however, you cannot
be asked to pay more than a $184 coinsurance for the echocardiogram. Therefore, we decided that provider has to reduce the coinsurance for the echocardiogram from $920 to $184.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the bitewings - four radiographic images (D0274), and the periodic oral evaluation (D0120) and the prophylaxis (D1110) received January 5, 2021.
You asked the Plan to pay an additional amount for the bitewing x-rays, periodic oral evaluation, and the prophylaxis. You say that the requested services were necessary. The Plan denied your request. The Plan says you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are only covered under this benefit up to 50% of the Plan's Maximum Allowable Fee when received from an out-of-network provider. If you see an out-of-network provider, you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan agreed to cover the requested services up to 50% of the Maximum Allowable Fee. Therefore, we decided that the Plan does not have to pay an additional amount for the bitewings - four radiographic images (D0274), and the periodic oral evaluation (D0120) and the prophylaxis (D1110) received January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan covers some services for the chronically ill. We looked at your request, the records in the case file, and the rules. Review of the file shows that you have none of the qualifying diagnoses for the requested services. You do not require intense care coordination, are not high risk for hospitalizations or high risk for adverse health outcomes. Based on this information, we decided that the Medicare rules for coverage of special supplemental benefits for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to reduce the copayments for the inpatient hospital stay from August 21, 2020, to August 23, 2020. We decided that the Plan does not have to reduce the copayments for the inpatient stays and the emergency room visit from May 23, 2020, to August 3, 2020.
You asked the Plan to reduce the copayments for the inpatient hospital stays, and the emergency room stay. You say that you would like the dates of service to be considered one continuous admission since it was the same issue within 60 days of discharge. The Plan says that you have been charged the correct cost-sharing amount.
We decided that the Plan has to reduce the copayments for the inpatient stay from August 21, 2020, to August 23, 2020. The record shows that you were admitted for two inpatient days from August 21, 2020, to August 23, 2020. ($390 x 2 inpatient days = $780).
The Plan says that you must pay a $1,560 copayment for the inpatient stay from August 21, 2020, to August 23, 2020. Based on the plan contract, however, you cannot be asked to pay more than a $780 copayment for the hospital stay. Therefore, we decided that the provider has to reduce the copayment for the inpatient stay from a $1,560 copayment to a $780 copayment.
We also decided that the Plan does not have to reduce the copayments for the inpatient stays and the emergency room visit from May 23, 2020, to August 3, 2020.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment for each day, days 1-5 of the inpatient hospital stay and a $90 copayment for the emergency room stay. See chart below.
Dates of Service
Service
Copayment
Number of Inpatient Days
Member Liability
May 23, 2020, to June 19, 2020
Inpatient stay
$390
5
$1,560 - This is less than the standard copayment amount.
July 14, 2020, to July 23, 2020
Inpatient stay
$390
5
$1,560 - This is less than the standard copayment amount.
July 27, 2020
Emergency room visit
$90
n/a
$90
July 30, 2020, to August 3, 2020
Inpatient stay
$390
4
$1,560
Total
$4,770
Therefore, we decided that the Plan does not have to reduce the copayments for the inpatient stays and the emergency room visit from May 23, 2020, to August 3, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
December 2, 2020.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the claim paid appropriately. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a $200 allowance every year. We looked at the file and the Plan's rules. The file shows the Plan paid the appropriate amount of $200 based on the eyewear allowance benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth for tooth #8 (D3310) and endodontic therapy, molar tooth for tooth #3 (D3330).
You asked the Plan to pre-approve endodontic therapy, anterior tooth for tooth #8 and endodontic therapy, molar tooth for tooth #3. You say that the services are necessary. The Plan denied your request. The Plan says the services are 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 endodontic therapy, anterior tooth for tooth #8 (D3310) and endodontic therapy, molar tooth for tooth #3 (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam provided on April 14, 2021.
You asked the Plan to pay for the comprehensive eye exam. The Plan denied your request. The Plan says you must use an in-network, Medicare-covered vision care 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 contract with the Plan also says that you must use an in-network Medicare-covered vision care provider. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam provided on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 40 additional one-way trips to facilitate dialysis treatments.

You asked the Plan to pre-approve additional trips. You say that you have no way to get to the needed dialysis appointments. The Plan denied your request. The Plan says rules for routine transportation 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 a maximum of 30 one-way trips per year to Plan-approved locations such as medical facilities.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's routine transportation benefit only allows for 30 one-way trips per year to locations such as medical facilities. The case record indicates that you have 2 one-way trips remaining for 2021. No exception can be granted to the Plan's routine transportation benefit. Therefore, we decided that the Plan does not have to pre-approve 40 additional one-way trips to facilitate dialysis treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The
Plan denied your request. The Plan says this was incorrectly coded, and should be HCPCS A6530.
The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve miscellaneous
compression stockings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Theracycle, exercise bike (E1399) purchased August 25, 2020.

You asked the Plan to pay for the exercise bike. You say that you are appealing the denial you thought that you had preauthorization resolved. The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

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. Therefore, we decided that the Plan does not have to pay for a Theracycle, exercise bike (E1399) purchased August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services provided October 29, 2020, to October 30, 2020.
You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that you would like this claim to be fully covered by the Plan. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.
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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a total cost share of $2,765.58 for the outpatient hospital services ($13,827.91 Medicare-allowed amount x 20% coinsurance). This service 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 coinsurance for the outpatient hospital services provided October 29, 2020, to October 30, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says ongoing needs can be provided for at a lower level of care such as at a skilled nursing facility.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for pain and gastroenteritis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol cap 5mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication falls under Part D coverage.

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 Dronabinol cap 5mg for the enrollee.
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 LTACH is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 enrollee appears to be worsening with a poor prognosis and requires additional short-term acute care services which can be safely received at the currently facility. The enrollee does not require services at the LTACH that are not already available at the current hospital. Transfer to a lower level of care may be considered when treatment has 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from
March 11, 2020, through May 10, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. The enrollee's needs are non-skilled.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from March 11, 2020, through May 10, 2020.