Persius/hicric huggingface dataset:
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 admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were receiving home health services through June 26, 2020. You required stand-by assistance with walking with a rolling walker. You required minimal assistance with activities of daily living. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF level of 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 SNF admission 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant.
You asked the Plan to pre-approve a dental implant. You say that the implant is necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The plan covers only oral exams, cleanings, fluoride treatment, and x-rays. Dental implants are not covered. Therefore, we decided that the Plan does not have to pre-approve a dental implant.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forTomographic Myocardial Perfusion Imaging (SPECT) (J1245, A9500, 78452, 93015) provided December 26, 2019.You asked the Plan to waive the copayment forthe Myocardial Perfusion study. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was 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 clearlysays that you must pay a $200 copayment for Nuclear Medicine Services. You have been asked to pay a $200 copayment for the Myocardial Perfusion study. The Myocardial Perfusion study falls within the Nuclear Medicine Services benefit category. This meansthat 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 forTomographic Myocardial Perfusion Imaging (SPECT) (J1245, A9500, 78452, 93015) provided December 26, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProlia for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy guidelines were not followed.Medicare covers Part B medications when they are reasonable and necessarybut 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 drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found step therapy, as outlined by the plan, requires enrollees either have a history of osteoporosis-related fracture or have trialed and failed or have a contraindication to zolendronic acid. There is no documentation of a pathologic fracture. The documentation does not outline contraindications or reasons why zolendronic acid were not considered. Without the support of the documentation, Prolia is not approved as step criteria is not met. 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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProlia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitoring system.You asked the Plan to pre-approvethe system. You say that this is medically necessary.The Plan denied your request. The Plan says the most recent records from the physician do not document that blood sugar is checked at least 4 times per day. 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 the system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation does not include a discussion of the frequency of finger glucose checks. Additionally, you are not noted to take insulin and there is no discussion how the continuous monitor would guide treatment. Without the support of the documentation, medical necessity cannot be determined.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 system have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuousglucose monitoring system.
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 the enrollee had a recent hospital admission due to heart failure and remains significantly deconditioned due to his medical problems. You say that the enrollee is in need of the requested shower bench so that he can self-bathe. You stated that you believe the shower bench is essential for the enrollee's well-being and you asked the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions, dental sedation, and dentures over the $1,000 benefit limit.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says there is a $1,000 benefit limit.
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 and services are subject to a benefit limitation. The plan only covers dental services up to a $1,000 benefit limit. You are responsible for any amount in excess of $1,000. The estimated cost of the requested dental services is more than $1,000. This means that all of the services cannot be approved, because you will be responsible for any amount over the benefit limit. Therefore, we decided that the Plan does not have to pre-approve dental extractions, dental sedation, and dentures over the $1,000 benefit limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve and pad (L1833, L2397, L2810) provided to the enrollee on March 18, 2020.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve and pad (L1833, L2397, L2810) provided to the enrollee on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you had major back surgery and require these services.The Plan denied your request. The Plan says that ongoing skilled services 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the outpatient clinic visit. We decided that the Plan does not have to waive the coinsurance for the outpatient clinic visit.
You asked the Plan to waive the coinsurance for the outpatient clinic visit. You say that this was a very brief, non-emergency consultation. You say that you shouldn't have to pay this amount. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the coinsurance for the outpatient clinic visit.
The Plan says that you must pay $453.39 for the outpatient clinic visit. Based on the Plan contract, however you cannot be asked to pay more than 40% coinsurance for the clinic visit. The allowed amount is $550.81 (40% x $550.81 = $220.32). Therefore, we decided that the Plan has to reduce the coinsurance for the outpatient clinic visit from $453.39 to $220.32.
We also decided that the Plan does not have to waive the coinsurance for the outpatient clinic visit.
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% coinsurance for out-of-network primary care physician services and physician specialist services. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient clinic visit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Symbicort.
You asked the Plan to pre-approve Symbicort. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Symbicort is 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 Symbicort.
Benefits for Symbicort 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-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested SNF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical history of hypertension, diabetes and glioblastoma multiforme who presentedto the acute hospital on 06/12/2020 with altered mental status and failure to thrive. He was treated in the hospital with Temodar, Keppra, Norco, metoprolol and insulin. He is weak and deconditioned and is working with physical and occupational therapy. He is walking 125 feet with a rolling walker and is minimum to moderate assist for transfers and activities of daily living. He is medically frail due to his malignancy and hospice care is reported as a consideration in the provided records. Family report inability to care for him at home.Based on the medical records provided this enrollee does not require skilled nursing services. Based on the medical records provided this enrollee does require skilled therapy services; however, the enrollee does not needdaily skilled services. Based on the medical records provided this enrollee does not require the services on an inpatient basis, in a skilled nursing facility setting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that 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 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 based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020) progressive lenses (V2781x2) anti-reflective coating (V2750x2) deluxe lens feature (V2702x2) trifocal lenses (V2303x2) and tint photocromatic lenses (V2744x2) provided February 1, 2020.
You asked the Plan to pay for the vision services. You say that you will return the glasses for a refund. The provider told you that the plan would cover $300 and you have to pay the rest. The Plan denied your request. The Plan says the correct cost share was applied per the plan 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). Your contract with the Plan clearly says that you must pay any amount above the $300 eyewear benefit. You have been asked to pay $599.00 for the vision services. The provider billed a total of $859. The plan paid $300. The remaining $599 is your responsibility. The vision services fall within the Vision 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 pay for the frames (V2020) progressive lenses (V2781x2) anti-reflective coating (V2750x2) deluxe lens feature (V2702x2) trifocal lenses (V2303x2) and tint photocromatic lenses (V2744x2) provided February 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Omnipod.
You asked the Plan to pre-approve an Omnipod. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems identified with code A9274 are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Omnipod have not been met. Therefore, we decided that the Plan does not have to pre-approve an Omnipod.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiogram provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the echocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized and network providers were available.
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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for the echocardiogram provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies are medically necessary for the enrollee. You say that the enrollee has urinary incontinence due to her severe physical disability. You asked the Plan to review their denial and approve the requested supplies. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you called 911 because you were having difficulty breathing. You say that you received a bill and when you spoke to the provider's billing department you were told that is a first responder fee and not an ambulance fee. You stated that you did not have a choice in who shows up when you called 911. You say that your previous ambulance bills have been paid by the Plan and your deductible was met. You stated that you would like to appeal the Plan's denial and would like the Plan to issue payment to the provider. 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 November 17, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent urinary catheters provided on November 27, 2019.
You asked the Plan to pay for intermittent urinary catheters (A4351). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation did not include a valid physician order and an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
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 physician order or proof of delivery for the supplies provided in this case. The physician order is for coude tip intermittent urinary catheters (A4352). The delivery ticket does not have the tracking number on it. 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 the intermittent urinary catheters provided on November 27, 2019.