Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity of this examination or that the member meets Medicare criteria for continued therapy services.

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 the additional physical therapy. 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 records do not demonstrate that his functional level requires 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 for physical therapy, by or under the supervision of a therapist.

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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 surgical treatment of a subdural hematoma. 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home sleep study (CPT code 95806).

You asked the Plan to pre-approve the home sleep study. You say that the enrollee has multiple risk factors for obstructive sleep apnea. The Plan denied your request. The Plan says the information sent in does not show that the enrollee has a lot of problems (symptoms survey- Epworth score 3/24 -normal). The Plan states the information sent in does not show that the enrollee wakes up gasping or choking and it does not show that the enrollee stops breathing while they are asleep. The Plan states the records do not show that the enrollee snores loud.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home sleep study have not been met. Home sleep testing is not covered for persons with moderate to severe pulmonary disease. Therefore, we decided that the Plan does not have to pre-approve the home sleep study (CPT code 95806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF. You say that discharge from the inpatient rehabilitation facility is anticipated, but the enrollee is not ready to go home. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.

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 SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, the enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for fever and encephalopathy. The enrollee's 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. 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 20, 2020.

You asked the Plan to pay for the dental services. You say that you were told the services were approved. The Plan denied your request. The Plan says the claim was processed correctly.

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. 

The file shows that you received an unspecified preventive procedure, and a complete series of radiographic images. Although the Plan offers a dental benefit in excess of Medicare coverage, these services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel provided on July 2, 2020.

You asked the Plan to pay for the respiratory panel. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the place of service on the CMS-1500form line 24B must reflect the location of the patient when the specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the respiratory panel have not been met. Specifically, this claim was billed with a laboratory place of service code, but the records indicate that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the respiratory panel provided on July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.

You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.

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 Evenity. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not tried and failed the required drug(s). Based on the medical records provided, there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Osteonecrosis of the jaw has been reported with Evenity, but is not reported as a commonly recognized adverse reaction to Forteo or Tymlos.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.

You asked the Plan to pay for intermittent limb compression device. You say that the services provided were medically necessary for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the enrollee's condition.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent disease testing.

You asked the Plan to pay for infectious agent disease test. You say that this testing is payable according to guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that viral panel testing of 6 or more pathogens is non-covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infectious agent disease test have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent disease testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtained prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or facility.

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 skilled nursing services 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 the ankle foot orthosis and heel stabilizer (L3170, L1971).

You asked the Plan to pay for the ankle foot orthosis and heel stabilizer. You say that these services were medically necessary. The Plan denied your request. The Plan says there is no evidence that the prescribing physician saw the enrollee.

The Plan follows Medicare rules. Medicare rules say that the ankle/foot orthosis must meet the Medicare criteria cited in the Rules section to be 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 ankle foot orthosis and heel stabilizer. Our reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found a physical examination of the ankle and foot would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the ankle and foot.

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 ankle foot orthosis and heel stabilizer have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and heel stabilizer (L3170, L1971).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by Fire Department on May 23, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Planpays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by Fire Department on May 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe CTscan, outpatient surgery, and chemotherapy drugs provided from March 16, 2020, to July 20, 2020.You asked the Plan to waive the cost share forthe CT scan and the chemotherapy. You say that you say the copayments are too high.The Plan denied your request. The Plan says the outpatient surgery on March 16, 2020 has been reprocessed with the correct $400 copayment and you have been charged the correct cost sharing amount for the remaining dates of service.

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 $200 copayment for all other diagnostic and nuclear medicine radiological services, a $400 copayment for outpatient surgery,and 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. You have been asked to pay a total of $2,924for the CT scan, outpatient surgery,and the chemotherapydrugs. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The chemotherapydrugs fallwithin the "Medicare Part B prescription drugs"benefit category.The outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. See chart below.Date of ServiceServiceAllowed AmountCoinsurance/CopaymentMember LiabilityMarch 16, 2020Outpatient surgery$6,684.52$400$400March 18, 2020Chemotherapy drugs$6.2420%$1.25April 27, 2020Chemotherapy drugs$2,923.2620%$584.65May 18, 2020CT scan$570.35$200$200May 27, 2020Chemotherapy drugs$2,922.2920%$584.45June 22, 2020Chemotherapy drugs$2,922.2920%$584.45July 7, 2020Chemotherapy drugs$2,845.3020%$569.06Total$2,924This 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 share forthe CT scan, outpatient surgery, and chemotherapy drugsprovidedfrom March 16, 2020, to July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2331, D2335, D0120, D0274) provided by an out-of-network dentist.

You asked the Plan to pay for out-of-network dental services. You say that you believed this dentist was in-network. The Plan denied your request. The Plan says out-of-network 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 when provided by an out-of-network dentist. 

Therefore, we decided that the Plan does not have to pay for dental services (D2331, D2335, D0120, D0274) provided by an out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on May 5, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider's facility is private and does not accept Medicare payments.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that would require the plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the eyeglasses purchased at an out of network (OON) provider.

You asked the Plan to provide reimbursement for the eyeglasses. You say that the glasses you had made were not made correctly, and you were not able to take them back. Instead, you went to another provider and bought new glasses. You feel this should be covered since the glasses you received were not correct. The Plan denied your request. The Plan says it is noted by the provider of the previous eyewear that you never contacted them to indicate an issue or request repair. There were no restrictions which would have prevented you from doing this. Since the plan has already paid for one pair of eyeglasses, the benefit was exhausted at the time you purchased the second pair.

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 routine eyewear, including complete frames and lenses, once per 12-month period.

We looked at the file and the Plan's rules. We find that you have received the maximum benefit for the 12-month period. 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 provide reimbursement for the eyeglasses purchased at an out of network (OON) provider.