Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left ankle-foot orthosis (L1971-LT) and a right-ankle foot orthosis (L1971-RT) provided to the enrollee on March 11, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the enrollee, at the originating site. We looked at the file and Medicare rules. In this instance, the records do not show that the enrollee was present at an originating site located in a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or a country outside of an MSA served by the telehealth network. Additionally, the record does not show that the encounter was conducted using an audio and video telecommunication system. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for a left ankle-foot orthosis (L1971-LT) and a right-ankle foot orthosis (L1971-RT) provided to the enrollee on March 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs rendered to you from February 7, 2019 to May 2, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is expensive. The Plan denied your request. The Plan says the coinsurance 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 all Part B drugs.
Review of the file shows that you received chemotherapy from February 7, 2019 to May 2, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the all Part B drugs 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.
The Plan has applied a grant towards your coinsurance, bringing the total amount you owe from $4,002 to $614.71.
Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs rendered to you from February 7, 2019 to May 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.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 indenying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found here are no documented daily skilled complex nursing or therapy needs. The documentation does not support that the enrollee would be able to participate in and benefit from skilled 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev capsules.
You asked the Plan to pre-approve Ofev capsules. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Ofev capsules are not covered under the enrollee's Medicare Part B 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 Ofev capsules.
Benefits for Ofev capsules 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need additional days in SNF to improve strength and mobility. The Plan denied your request. The Plan says that there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services.You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee is not aggressive, and there is no significant deviation from baseline.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued care beyond February 21, 2020 was requested for 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 continued services. Our physician reviewer found that it did not appear that the services were reasonably expected to improve the enrollee's condition, or for the purpose of diagnosis beyond the date in question. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question as she was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations, and was cooperative/compliant with treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation feature (E2300).
You asked the Plan to pre-approve the power seat elevation feature. You say that you use this option to transfer to your bed, into the shower and into your car. You state the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not considered medical in nature and is considered a convenience item and is not a covered benefit.
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 pre-approve power seat elevation feature (E2300).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.
You asked the Plan to pre-approve additional transportation. You say that the enrollee needs transportation to
cardiac rehab and clinic visits. The Plan denied your request. The Plan says the enrollee has 4 trips remaining
under their 24-trip limit for the transportation benefit.
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 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Once 24 trips have been used, the enrollee
will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided
that the Plan does not have to pre-approve additional routine transportation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network providers.
You asked the Plan to provide coverage for out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says the requested provider is not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must provide coverage 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 provide coverage for these items/services. Therefore, we decided that the Plan does not have to provide coverage for out of network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided on August 22, 2019.
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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 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 chiropractic treatment provided on August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the myocardial imaging to be provided by an out of network (OON) provider.You asked the Plan to pre-approve myocardial imaging. You say that the enrollee needs this service.The Plan denied your request. The Plan says this service is available in network.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 myocardial imaging to be provided by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1851-RT), a right suspension sleeve
(L2397-RT), a right shoulder orthosis (L3960-RT), and a right-ankle foot orthosis (L1971-RT provided to the
enrollee on September 26, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth
guidelines have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1851-RT), a right suspension sleeve (L2397-RT), a right shoulder orthosis (L3960-RT), and a right-ankle
foot orthosis (L1971-RT provided to the enrollee on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aflibercept injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documented failure or contraindication to the health plan's preferred products.
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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided records and statements did not show any evidence that the enrollee had tried and failed Avastin for their condition. Avastin would not be any less effective than the requested Aflibercept injection, based on a randomized clinical study comparing these two medications for the treatment of AMD which suggested there was no significant difference in outcome. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Aflibercept injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August6, 2019 through August 9, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 6, 2019 and discharged on August 9, 2019. You were asked to pay a $335 copayment per day from August 6, 2019 through August 8, 2019, days 1-3 of your inpatient hospital care. You were discharged on August 9, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $335 copayment per day required for days 1-5. 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 inpatient hospital care from August 6, 2019 through August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940).
You asked the Plan to pre-approve these services. You say that you have had pain off and on for three years but more so within the last six to eight months. The Plan denied your request. The Plan says you do not meet criteria for coverage of chiropractic treatment as the medical documentation provided does not demonstrate subluxation of the spine by x-ray or by physical exam.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Specifically, the record does not show subluxation of the spine by x-ray or physical exam. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the manual wheelchair purchased on August 25, 2019 from an OON provider.
You asked the Plan to reimburse you for the manual wheelchair. You say that you could not walk or stand so your spouse went and purchased a wheelchair for you. The Plan denied your request. The Plan says you did not request prior authorization.
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 reimburse you 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the manual wheelchair purchased on August 25, 2019 from an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management service, before and/or after direct patient care, first hour (99358-25) provided June 17, 2019.
You asked the Plan to pay for prolonged evaluation and management service. You say that the provider saw this enrollee and delivered high level of care for complex case. Please reprocess and pay and higher allowable. The Plan denied your request. The Plan says the records do not support the service billed.
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 99358-25 is prolonged evaluation and management service, before and/or after direct patient care, first hour.
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 prolonged evaluation and management service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided do not include the total duration of face-to-face time spent by the clinician on the date of service even when the time spent is not continuous. Therefore, the service cannot be validated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prolonged evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management service, before and/or after direct patient care, first hour (99358-25) provided June 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve narrow-band ultraviolet B (NVUVB) phototherapy.
You asked the Plan to pre-approve NVUVB therapy. You say that the enrollee's condition significantly affects quality of life, and she needs this narrow-band ultraviolet B treatment. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this procedure is not indicated for the enrollee's condition.
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 NVUVB therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is a standard treatment for 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 NVUVB therapy have been met. Therefore, we decided that the Plan has to pre-approve narrow-band ultraviolet B (NVUVB) phototherapy.