Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid monaural in ear (V5050) received November 23, 2020 from a non-participating hearing provider.
You asked the Plan to pay for the hearing aid monaural in ear. You say that the hearing aid you received from the Plan-approved hearing vendor was not compatible with your equipment at home. The Plan denied your request. The Plan says the hearing aid benefit is limited to Plan-participating providers.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when rendered by a Participating Provider in the Plan's hearing vendor network. We looked at the file, and the Plan's rules. You purchased your hearing aid from a non-participating hearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid monaural in ear have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid monaural in ear (V5050) received November 23, 2020 from a non-participating hearing provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole magnesium capsule 40mg DR.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no Part D benefit with this plan.
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 Esomeprazole magnesium capsule 40mg DR.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ophthalmic diagnostic imaging, the Part B drugs, and the eye injections provided on November 17, 2020 and December 8, 2020.

You asked the Plan to waive the cost share for the diagnostic imaging, the Part B drugs, and the eye injections. You say that you are asking why this was not paid by the Plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 $40 copayment for in-network physician services (including surgery second opinion, Medicare-covered telehealth or urgently needed services) and 20% coinsurance all other in-network drugs covered under Medicare Part B. 

You have been asked to pay a total of $465.70 for the diagnostic imaging, the Part B drugs, and the eye injections. The diagnostic imaging and the eye injections fall under the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drugs fall under the "Medicare Part B prescription drugs" benefit category. See provided chart.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the ophthalmic diagnostic imaging, the Part B drugs, and th eye injections provided on November 17, 2020 and December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no confirmation that the enrollee is checking their blood sugar four or more times per day.

The Plan must follow Medicare rules. The rules say that continuous glucose monitors are covered under specific indications. There are no medical records provided by the requestor to show that any of the required criteria have been met.

Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on October 30, 2020.

You asked the Plan to pay for the assistant services. You say that the surgical assistant was chosen at the surgeon's discretion. The Plan denied your request. The Plan says the claim denied correctly.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. 

In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 26990. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on October 30, 2020.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be safely rendered in a lower level of care.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing services or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. Services in the home or an assisted living facility with home health services or in a long-term care facility on a part time basis appear 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 the 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health skilled nursing services (G0299) and home health aide services (G0156).

You asked the Plan to pre-approve the home health services. You say that your primary doctor requested physical therapy and someone to come to your house, but they could not help you because you're not house bound. Then you received authorization to go for therapy 20 miles away from your house. The Plan denied your request. The Plan says home health nursing is not medically necessary for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the enrollee has been attending outpatient occupational therapy, primary care and medical specialist appointments. As such, the enrollee does not appear to be homebound. Therefore, the requested home health services are not medically necessary or reasonable.

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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health skilled nursing services (G0299) and home health aide services (G0156).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81403, 81404, 81407, 81408, 81479)
provided September 1, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this type of lab test is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or
documented cardiovascular disease.

We looked at the file and Medicare rules. The test performed was a cardiovascular risk assessment panel. This
service is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81401,
81403, 81404, 81407, 81408, 81479) provided September 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided on November 4, 2020 and November 6, 2020.

You asked the Plan to waive the copayment for the emergency care. You say that because of a mistake during surgery you had to visit the hospital so you should not have any copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $90 copayment for Emergency Care. 

You have been asked to pay a $90 copayment for the emergency care. The emergency care falls within the Emergency 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 emergency care provided on November 4, 2020 and November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detoxification treatment.

You asked the Plan to pre-approve inpatient detoxification treatment. 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 inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient detoxification treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health/detoxification treatment beyond the date in question of May 17, 2021 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations. You were not showing any aggressive behaviors and were being cooperative and compliant while not showing any withdrawal symptoms.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient detoxification treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient detoxification treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says there is no
documentation of hypoxia, hypercapnia, or treatment with a continuous positive airway pressure device
(CPAP) ruled out.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 a home ventilator. Our physician
reviewer found that the enrollee has a diagnosis of chronic obstructive pulmonary disease, but this is not
documented with pulmonary function tests. There is no documentation of carbon dioxide (CO2) retention.
Medicare does not cover a home ventilator when used as BiPAP. The enrollee's use of the ventilator does not
meet the minimum criteria of at least 4 hours per day for 70% of days. Therefore, the requested home ventilator
is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgery services provided on October 23, 2020.

You asked the Plan to pay for the assistant surgery services. You say that assistant surgeon services were in the best interest of the enrollee. The Plan denied your request. The Plan says assistant surgeon services for the procedure percutaneous vertebral augmentation is not covered.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 22514. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgery services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services provided on October 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device is unproven.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life2000 system (E0466).

You asked the Plan to pre-approve a Life2000 system. You say that the requested item is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested item is not reasonable and necessary in this case.

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 a Life2000 system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Life2000 system is not a true ventilator. It provides positive pressure support during activity. The system has not been shown to be safe and beneficial in the treatment of chronic obstructive pulmonary disease (COPD). Support with bilevel positive airway pressure (BiPAP) at night can be beneficial in COPD with carbon dioxide (CO2) retention and frequent exacerbations, but that is not the case here, and that is not what is being prescribed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Life2000 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life2000 system (E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has cancer with fracture
that is at least eight months old. The physical exam does not document any spine dysfunction. The notes
indicate the enrollee is not in severe pain. The criteria for kyphoplasty are not met and the services are
therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve kyphoplasty.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance oxygen and supplies (93040, A0422) provided on December 18, 2020, during emergency ambulance transportation.

You asked the Plan to pay for the ambulance supplies. You say that these benefits should be covered as this was an emergency ambulance transport. The Plan denied your request. The Plan says the ambulance service and ground mileage have been approved. However, the special supplies used during the ambulance service cannot be approved as they are included in the base ambulance transportation payment.

The Plan must follow Medicare rules. Medicare rules say that patient care equipment and first aid supplies provided during emergency ambulance transportation are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met. Specifically, the items/services at issue are not covered benefits of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for ambulance oxygen and supplies (93040, A0422) provided on December 18, 2020, during emergency ambulance transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injections (J7326).

You asked the Plan to pre-approve the Gel-One injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that a repeat Intra-articular Hyaluronan Injection can be covered when the last injection (in a prior course) was given at least six (6) months ago. 

We looked at the file and Medicare rules. The record shows injections were last received in December 2020. Six months has not yet passed since the last injection. Based on this information, we decided that Medicare rules for coverage of the Gel-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One injections (J7326).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide visits.

You asked the Plan to pre-approve home health aide 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 HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee's care needs appear to be custodial. As such, the services of a home health aide are not medically necessary, reasonable or covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide visits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and emergency transport provided on
July 29, 2020.

You asked the Plan to pay for the transportation services. You say that the over-payment should not be offset.
You say that you have requested that the provider write the refund. The Plan denied your request. The Plan
says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan
also says it is the provider's responsibility to verify the member's coverage before rendering services and to
know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ground mileage and emergency transport provided on July
29, 2020.