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

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. You say that the enrollee has had adverse reactions to the medications that she has tried. You also say that the enrollee is not a good candidate for the preferred drugs. The Plan denied your request. The Plan says the provided documentation does not shows that the enrollee has tried and failed the preferred drugs. The Plan also says that the requested drug is not medically necessary.

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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found the provided documentation does not show that the enrollee has tried and failed the preferred drugs. The reviewer also found that the provided medical records and data in the Medicare-approved drug compendia do not indicate that the Plan's required drugs would likely be less effective or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug is not medically reasonable or 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) provided July 2, 2020.

You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan denied your request. The Plan says this claim is a duplicate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 76770 is not supported in the medical record. Specifically, payment for CPT code 76770 provided on July 2, 2020 was already issued. The documentation does not support more than 1 unit of this service. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76770) provided July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 27, 2020.

You asked the Plan to waive the copayment for a knee injection. You say that you did not have a surgery. You say that you had a knee injection. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery/in-network/outpatient hospital. 

You have been asked to pay a $150 copayment for a knee injection. The knee injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. A knee injection falls within the outpatient surgery/in-network/outpatient hospital 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 an outpatient surgery provided by a participating provider on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 21, 2020, by an outof-
network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are
in-network providers 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on August 21, 2020,
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the domiciliary or rest home visit provided on September 2, 2020.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services were rendered by an out-of-network provider. The Plan also says that prior authorization was not obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the domiciliary or rest home visit provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that you feel that the services are medically
necessary. The Plan denied your request. The Plan says a standard wheelchair can be provided as an
alternative.

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 wheelchair. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation is conflicting on whether or not the enrollee has a mobility limitation.
Furthermore, it is not clear that a mobility limitation significantly impairs the enrollee's ability complete
MRADLs. On exam she had normal strength and sensation. She also was noted to have normal gait without
joint instability. There is no detailed upper extremity neuromuscular exam indicating that she cannot resolve
any gait issue with a cane or walker. The documentation does not reveal a detailed home assessment indicating
the enrollee's home is appropriate for the wheelchair. There is no evidence that this wheelchair will
significantly improve the enrollee's ability to perform MRADLs. There is no evidence the enrollee or caregiver
can propel the wheelchair or that the enrollee is unable to use a standard wheelchair in the home and requires a
lightweight wheelchair.

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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lightweight wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic 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 has deluxe features that exceed medical needs.

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 medical records provided do not meet the requirements listed in the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k) for Medicare coverage for the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702). At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. 

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 a MyoPro Motion G orthotic device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the continuation of SNF care. You say that the records provided support the need for continued SNF care. The Plan denied your request. The Plan says the criteria for a continued SNF stay have not been met. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis in a long-term care facility, or in the home with home health care services.

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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has a medical history that includes heart disease, stroke, diabetes, and unspecified dementia with behavioral disturbance. The enrollee's blood sugar has been high, and she is on oral hypoglycemic medication. The enrollee was an assist of 1 with transfers and daily activities of daily living as of February 4, 2021. On February 17, 2021 the enrollee required moderate assistance with lower extremity dressing, bathing, and toileting. The records do not show that the enrollee currently requires skilled nursing services. The records show that the enrollee does require skilled therapy services, but not on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a SNF.

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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99282) provided on October 13, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be charged for this visit because you only saw a nurse. The Plan denied your request. The Plan says this processed 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 each Medicare-covered emergency room visit. 

You have been asked to pay a $90 copayment for an emergency room visit. 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 an emergency room visit (99282) provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on September 3, 2020.

You asked the Plan to pay for the bitewing x-ray. You say that you believe this bitewing x-ray should be covered. The Plan denied your request. The Plan says the frequency limit for this service had been exceeded.

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, bitewing x-rays are limited to one of codes D0270, D0272, D0273, D0274, or D0277 once per plan year. The record shows that you received bitewing x-rays (D0274) on March 3, 2020, and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331), the surgical procedure for isolation of tooth with rubber dam (D3910), the canal preparation and fitting of preformed dowel or post (D3950), and the unspecified endodontic procedure (D3999) provided on October 5, 2020.

You asked the Plan to pay for the dental services. You say that these procedures which dealt with possible infection issues only makes sense under any circumstances. You also say that if the insurance does not pay for root canals and posts when the tooth was so decayed that had crowns, you would like to know which procedure should be used. The Plan denied your request. The Plan says the services that you received are not listed as covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331), the surgical procedure for isolation of tooth with rubber dam (D3910), the canal preparation and fitting of preformed dowel or post (D3950), and the unspecified endodontic procedure (D3999) provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June
16, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for an OON domiciliary or rest home visit. You say that the enrollee did not provide
correct insurance information. The Plan denied your request. The Plan says this service was not authorized.

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 the domiciliary or rest home visit (99336)
provided on June 16, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).

You asked the Plan to pre-approve foot orthotics. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that the enrollee does not wear a leg brace. The enrollee does suffer from diabetic foot disease; however, the requested foot orthotic (L3000) is not a diabetic-shoes item. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of the specifically requested orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received on July 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

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 only covers routine vision care provided by in-network providers. 

We looked at the file and the Plan's rules. The vision services were provided by an out-of-network provider. Out-of-network vision care is not covered under your plan. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services you received on July 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on February 26, 2019.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like reconsideration because you did not receive proper notice of the member's benefit determination. The Plan denied your request. The Plan says this claim was filed past the 12 month allowable time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychiatric diagnostic evaluation was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on February 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VP-Vite Rx for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 VP-Vite Rx for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on May 11, 2020, by an
out-of-network provider.

You asked the Plan to pay for the dermatology services. You say that the enrollee failed to update you with
updated insurance information. 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the dermatology services provided on May 11, 2020, by an out-of-network
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is necessary for the enrollee's condition. The Plan denied your request. The Plan says LTACH care is not medically necessary at this time.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.