Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there was no documentation of a plan for new home care services.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided there is no documentation that skilled therapy services are required to effectively
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a
maintenance program to maintain your level of function and/or prevent deterioration. There is no provider
medical note or provider order documenting need for the requested service or ordering the requested service.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for evaluation visit. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 the medical services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames and lenses provided September 12, 2020.
You asked the Plan to pay for the eyeglasses. You say that the out-of-network provider was more economical,
and the eyeglasses should be covered. The Plan denied your request. The Plan says eyeglasses are only covered
when obtained from the plan-contracted provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when obtain from a plan-contracted provider.
We looked at the file and the Plan's rules. The eyeglasses were purchased from an out-of-network provider.
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for eyeglass frames and lenses provided September
12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with an OON provider.
You asked the Plan to pre-approve the OON dental services. You say that your situation is unique and warrants
further consideration for coverage. You say that the emotional toll of being shuttled from doctor to doctor can
adversely affect medical outcomes. You say that starting over with a new provider would be distressing and
counterproductive. The Plan denied your request. The Plan says the services in dispute 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 benefits are limited to services
performed by in-network providers. The provider you are requesting services from is out-of-network.
Therefore, we decided that the Plan does not have to pre-approve dental services with an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outer surface covering system (L5964).
You asked the Plan to pre-approve the outer surface covering system. You say that this service is necessary for the enrollee's condition. The Plan denied your request. The Plan says this service is not coverd.
The Plan must follow Medicare rules. Medicare rules say that the outer surface covering system is used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the usual level of protection. We looked at the file and Medicare rules. The case file does not indicate that the enrollee needs protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage of the outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve the outer surface covering system (L5964).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650).

You asked the Plan to pay for an LSO. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.

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 pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided by an out of network (OON) provider.

You asked the Plan to pay for the out of network nursing facility care. You say that this provider sees patients on a random basis without scheduled appointments and therefore you would not have been able to obtain prior authorization. The Plan denied your request. The Plan says the services were provided out of network and prior authorization was not obtained by the provider or facility. The provider should have verified the member's eligibility and benefits before providing services.

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 the nursing facility care (99308) provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for life vest (K0608) provided on October 21, 2020.
You asked the Plan to waive the coinsurance for life vest. You say that the item should be covered. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for life vest. This service falls within the durable medical equipment (DME) and related supplies 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 life vest (K0608) provided on October 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for methylprednisolone acetate (a Medicare Part B prescription drug) and injection procedures provided on August 18, 2020 and October 13, 2020.
You asked the Plan to waive the cost-sharing for Part B drugs and specialist services. You say that you were told this cost-sharing would be waived. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 20% coinsurance for Part B drugs and $35 copayment for each specialist visit. The allowed amounts of the Part B drugs total $22.89, resulting in a coinsurance amount of $4.58. There were 2 specialist visits, resulting in a copayment amount of $70. Your total cost-sharing obligation is therefore $74.58. You have been asked to pay 20% coinsurance for Part B drugs and $35 copayment for each specialist visit. Part B drugs and specialist services fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-sharing for methylprednisolone acetate (a Medicare Part B prescription drug) and injection procedures provided on August 18, 2020 and October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee could be treated by an in-network chiropractor.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram report (93010) provided on September 23, 2020.
You asked the Plan to pay for the electrocardiogram report. You say that you would like reconsideration because the medical records show that this provider read and confirmed the electrocardiogram. The Plan denied your request. The Plan says CPT code 93010 has been previously processed and paid for this date of service.
The Plan must follow Medicare rules. Medicare rules say that generally, carriers must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram report have not been met. Specifically, the documentation does not support that the interpretation was conveyed to the emergency physician in time to contribute to the diagnosis and treatment of the patient. Therefore, we decided that the Plan does not have to pay for the electrocardiogram report (93010) provided on September 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided on October 15, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because this is the only hospital in the area and the services were urgent. The Plan denied your request. The Plan says the office visits were billed with place of service 21 which is inappropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99284 is not supported in the record. Specifically, it is not appropriate to bill an emergency department visit with an inpatient place of service code. Additionally, the documentation submitted does not include evidence of the services rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided on October 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-Ray examination.

You asked the Plan to waive the copayment for X-Ray. You say that this was part of pre-operative testing. 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 $40 copayment for each in-network X-Ray.

You have been asked to pay $40 copayment for X-Ray. X-Ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 X-Ray examination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. His medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided at a low level of care.

Additionally, there is a not reasonable expectation that this patient will be able to fully participate in and benefit from an 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you were not advised that this provider was OON. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.

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 comprehensive oral evaluation and complete series of intraoral x-rays provided by an OON provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomographic angiography (CTA) of the chest for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the results of the approved scan of the abdomen and pelvis must be reviewed.
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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee not only has bilateral blue toe syndrome which provides a valid indication for CTA aorta and runoff, but she also has significant carotid stenosis on ultrasound as well as a history of mitral regurgitation and left atrial enlargement. It would be prudent to evaluate the great vessels in the chest for any evidence of aneurysm or other potentially serious vascular abnormality including disease at the origin of the stenotic carotid arteries in order to assess risk for this patient. In addition her renal function has been borderline in the past with GFR of 48. As such minimizing contrast injection for this patient is a good idea. The CTA of the chest, abdomen and pelvis as well as the runoff can all be done with a single contrast injection at the same sitting thus avoiding the need for a second injection for a chest CTA done at a later date. For these reasons the requested CTA of the chest should be added to the already approved CTA of the aorta and runoff. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomographic angiography (CTA) of the chest for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee. The
Plan denied your request. The Plan says step therapy criteria has not been met.
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 Prolia. Our reviewer says that the
request does not meet step therapy criteria. Our physician reviewer found the patient has not tried and failed the
required drug Zoledronic Acid and does not have a history of an osteoporosis-related fracture. There is no
documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely
have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on October 15, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these services are 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on October 15, 2020.