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

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for an ultrasound and lab work provided by a participating provider on January 12, 2021, to January 13, 2021.
You asked the Plan to waive the coinsurance for an injection and copayment for an ultrasound and lab work. You say that you disagree with these charges. The Plan denied your request. The Plan says the correct charges have 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 20% coinsurance for Medicare Part B prescription drugs and a $10 copayment for outpatient diagnostic tests/basic imaging service and outpatient diagnostic tests/lab.
You have been asked to pay a 20% coinsurance of the allowed amount for Medicare Part B prescription drugs. The total allowed amount is $333.98. The amount you are being asked to pay for an injection is $66.80 ($333.98 x 20% = $66.80). You have been asked to pay $10 copayment for an ultrasound and lab work. The total amount you are being asked to pay is $86.80 ($66.80 + $10 + $10 = $86.80). An injection falls within the Medicare Part B prescription drugs benefit category. An ultrasound and lab work falls within the outpatient diagnostic tests/basic imaging service and outpatient diagnostic tests/lab benefit category. The correct charges have been applied to the services that were provided. 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 an injection and copayment for an ultrasound and lab work provided by a participating provider on January 12, 2021, to January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device and accessory (E0675,
E0673) provided March 5, 2021.
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says this item is not covered by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675
is used only for peripheral artery disease and not eligible for coverage. Pneumatic compression device related
accessories will not be covered when the base pneumatic compression device is not eligible for coverage.
We looked at the file and Medicare rules. In this case, the pneumatic compression device coded as E0675 is not covered. In addition, the accessory E0673 is not covered since the base pneumatic compression device is not covered. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and accessory (E0675, E0673) provided March 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injection services.
You asked the Plan to pre-approve Synvisc injection services. You say that imaging has shown joint effusion and the enrollee has ongoing pain for 3 months. You say that the enrollee has tried 2 cortisone injections with no lasting relief. You say that the enrollee is unable to complete activities of daily living without discomfort. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of the requested injection services.
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 Synvisc injection services. Our reviewer says that Synvisc injection services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have degenerative changes and has not had physical 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 Synvisc injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injection services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits.
You asked the Plan to pre-approve physical therapy visits. 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 Medicare pays for medically necessary outpatient therapy. 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 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.
Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy visits.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve maxillary antrostomy services.
You asked the Plan to pre-approve maxillary antrostomy services. You say that the enrollee is in pain and has facial pressure. You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says that the guidelines for coverage have not been met. The Plan says that medical studies haven't proven that the requested procedure is helpful for treatment of chronic sinusitis.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 maxillary antrostomy services. Our reviewer says that maxillary antrostomy services are considered medically reasonable and necessary in this case. Our physician reviewer found functional endoscopic sinus surgery, known by the acronym FESS, is intended to restore physiologic sinus ventilation and drainage, which can facilitate the gradual resolution of mucosal disease. In this case, the record indicates that the enrollee has a history of asthma and chronic sinusitis and rhinitis. The enrollee has persistent postnasal drip and sinus infections twice a year. She also has morning headaches and facial pressure. Imaging demonstrates a maxillary antrum retention cyst that partially obstructs the ostium. Endoscopy demonstrated turbinate hypertrophy and septal deviation. The record establishes that the enrollee has failed medical therapy. The totality of the record supports the medical necessity and reasonableness of 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 maxillary antrostomy services have been met. Therefore, we decided that the Plan has to pre-approve maxillary antrostomy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from February 8 through February 15, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the hospital is charging you for additional days as an inpatient even though you were not admitted to the hospital. The Plan denied your request. The Plan says you are only being charge a copayment for four days, not seven days. The correct cost share has applied to the claim.

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 $325 copayment per day for Inpatient Hospital Services. 

You have been asked to pay $1300 in copayments (a $325 copayment per day for four days) for the inpatient hospital stay. You have been asked to pay copayments for four days of inpatient care, not for seven days. The inpatient hospital stay falls within the Inpatient Hospital Services benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay from February 8 through February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided on February 19, 2021 and April 2, 2021 by an out of network provider.

You asked the Plan to pay for the office visits. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request authorization for the out-of-network 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 services at issue in this appeal. 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 the office visits provided on February 19, 2021 and April 2, 2021 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you have no family or assistance at home. You say that you need 24-hour care due to lack of ambulation and wound care. You say that, without SNF care, you could end up back in the hospital or with a fatal condition. You say that the levels of therapy at a SNF are much easier on you than the intensive inpatient level of rehabilitation.
The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met in the current IRF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and was to complete a course of IV antibiotics. The enrollee had stable vital signs, was treated for a wound infection, and had a wound vac. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a minimal assist level with bed mobility and maximal assist of 2 for transfers. The enrollee required varying assist with activities of daily living. There are identifiable skilled nursing service needs and identifiable skilled therapy service needs. However, these needs are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Apligraf.
You asked the Plan to pre-approve Apligraf. 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 follows Medicare rules. Medicare rules say that skin substitute grafts are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Apligraf. Our reviewer says that the services are not medically necessary.
Our physician reviewer found the review indicates that the enrollee has a traumatic wound to the right lower leg. The wound is documented as improving with a decrease in wound size with good granulation tissue noted. The member is responding to conservative wound care and debridement. There are no barriers to wound healing such as tobacco use, uncontrolled diabetes, venous insufficiency or infection. The documentation indicates that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Apligraf have not been met. Therefore, we decided that the Plan does not have to pre-approve Apligraf.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), preventive procedure (D1999), four gingival irrigations (D4921 x4), and four periodontal procedures (D4999 x4) provided on March 18, 2021.

You asked the Plan to pay for the oral hygiene instructions, preventive procedure, gingival irrigations, and periodontal procedures. You say that your dentist said you needed these services, or you run the risk of losing your teeth. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 oral hygiene instructions (D1330), preventive procedure (D1999), four gingival irrigations (D4921 x4), and four periodontal procedures (D4999 x4) provided on March 18, 2021.
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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for LTACH care 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 was admitted to the hospital for acute hypoxic respiratory failure requiring intubation. He was extubated and reintubated on July 13, 2021. His hospitalization was complicated by acute encephalopathy, hyperglycemia, acute kidney injury, urinary tract infection, and pneumonia. The enrollee has not had prolonged mechanical ventilation of 21 days as defined in Medicare guidelines. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Albuterol inhaler provided on July 29, 2021.
You asked the Plan to pay for the Albuterol inhaler. You say that you had trouble breathing, and qualified personnel taught you how to use the inhaler. The Plan denied your request. The Plan says this drug is a self-administered drug and is not Part B covered.
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 pay for the Albuterol inhaler provided on July 29, 2021.
Benefits for the Albuterol inhaler 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 physician services provided on February 16, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on February 16, 2021 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided February 17, 2021 to February 19, 2021.
You asked the Plan to waive the copayment for the hospital care. You say that the summary of benefits states that if you are admitted to the hospital within 24 hours, you do not have to pay your share of the costs for emergency care. Please review and process for payment. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $289 copayment per day for inpatient hospital days 1-6. You have been asked to pay $90 copayment for the hospital care. Since the amount is less than the copayment amount, you are responsible for the lesser amount. The 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 care provided February 17, 2021 to February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a full face mask for a CPAP device (A7030), a non-disposable CPAP filter (A7039), and a miscellaneous DME supply (A9900) provided on October 13, 2020.
You asked the Plan to pay for a full face mask for a CPAP device, a non-disposable CPAP filter, and a miscellaneous DME supply. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met because no valid proof of delivery has been provided.
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 a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a full face mask for a CPAP device (A7030), a non-disposable CPAP filter (A7039), and a miscellaneous DME supply (A9900) provided on October 13, 2020.