Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no advantage to transferring the enrollee.
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. 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 he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a nebulizer device (E0570) purchased on December 26, 2020, from an online retailer not enrolled in the Medicare program.
You asked the Plan to pay for a nebulizer. You say that the enrollee purchased the nebulizer under critical time constraints due to emergency circumstances. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a nebulizer device (E0570) purchased on December 26, 2020, from an online retailer not enrolled in the Medicare program.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on February 26, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the ER due
to your lab work being read incorrectly. 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 $90
copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit
took place, the correct copayment has been applied. An emergency room visit 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 an emergency room visit
provided by a participating provider on February 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299) provided December 4, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says a correct claim is needed.
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 G0299 is not supported in the medical record. Specifically, the claim was not billed on the UB-04 form and did not include required HHA information. 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 pay for home health services (G0299) provided December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment(DME) defined by codes
L0648, L1852 and E0691 provided to the enrollee on January 26, 2021.
You asked the Plan to pay for the DME. 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 for the durable medical equipment(DME) defined by codes L0648, L1852 and E0691 provided to the
enrollee on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve white glass crowns for teeth #'s 8, 9, and 11.
You asked the Plan to pre-approve the crowns. You say that these crowns should be covered. The Plan denied your request. The Plan says the requested crowns are not needed as there is no documented issue with your existing crowns.
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 Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the documentation does not support that replacement of the existing crowns is medically necessary. Our physician reviewer found teeth 8,9 and 11 have existing crowns on each tooth. There has been no supplied justification for replacement of any of the teeth in question. There is no recurrent decay seen on the provided x-rays. The documentation does not provide a narrative as to why the existing crowns are no longer serviceable. Given the lack of support in the documentation for replacement of the existing crowns, there is no medical necessity found. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve white glass crowns for teeth #'s 8, 9, and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and treatment of root canal obstruction; non-surgical access (D3331) provided February 12, 2021.
You asked the Plan to pay for the panoramic x-rays and treatment of root canal obstruction. You say that if you had known the dentist did not accept Medicare you would not have gone to them for services. The Plan denied
your request. The Plan says the provider who rendered the services has opted out of Medicare and therefore the 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. The Plan covers the panoramic x-rays and treatment of root canal obstruction when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at this the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-rays and treatment of root canal obstruction have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and treatment of root canal obstruction; non-surgical access (D3331) provided February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemotherapy administration (51720, J9031) provided July 17, 2017 to November 6, 2017.
You asked the Plan to waive the copayment for the chemotherapy administration. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing 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 clearly says that you must pay a 20% coinsurance for Part B drugs. You have been asked to pay a 20% coinsurance for the chemotherapy administration. The chemotherapy administration falls within the Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for chemotherapy administration (51720, J9031) provided July 17, 2017 to November 6, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a virtual fleet feet program provided for the 2020 benefit allowance.
You asked the Plan to reimburse you for a virtual program. You say that this program is a structured, demanding exercise program to prepare runners and walkers for a 5k, and includes strength training, walking and running. The Plan denied your request. The Plan says they are unable to approve your request for reimbursement of the 2020 Allowance Benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says a fitness center, weight watchers, acupuncture, activity tracker allowance can be used toward a gym membership or weight watchers' program. The Plan's rules for coverage of gym benefits have not been met because you are requesting reimbursement for a service that is not a covered benefit with your wellness allowance benefit. The records show you are requesting reimbursement for a virtual program to prepare for a 5k race. Therefore, we decided that the Plan does not have to reimburse you for a virtual fleet feet program provided for the 2020 benefit allowance.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Oxaliplatin and Kanjinti for the enrollee.
You asked the Plan to pre-approve Keytruda, Oxaliplatin and Kanjinti. You say that this regimen is highly
active and may substantially improve this patient's life expectancy and quality of life. The Plan denied your
request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Keytruda, Oxaliplatin and Kanjinti. Our
reviewer says that Keytruda, Oxaliplatin and Kanjinti are not medically reasonable and necessary for the
enrollee in this case. Keytruda, Oxaliplatin and Kanjinti are not FDA-approved for the enrollee's diagnosis.
The use of these drugs are not supported by one of the major drug compendia or by clinical research that
appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does
not meet criteria for coverage of Keytruda, Oxaliplatin and Kanjinti.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda, Oxaliplatin and Kanjinti have not been met. Therefore, we decided
that the Plan does not have to pre-approve Keytruda, Oxaliplatin and Kanjinti for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can have the care she needs at home with home health care or at an alternative level of care within the nursing home.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation inpatient mental health care provided to the enrollee from August 5, 2021, forward.
You asked the Plan to pre-approve inpatient mental health 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 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 mental health care. Our physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental
health treatment beyond the date in question of August 5, 2021, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as the enrollee awaited placement. 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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation inpatient mental health care provided to the enrollee from August 5, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compounded Clindamycin capsule, prednisone tablet, nystatin suspension, and M-dryl liquid.
You asked the Plan to pre-approve compounded Clindamycin capsule, prednisone tablet, nystatin suspension, and M-dryl liquid. You say that the options for care are limited. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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 compounded Clindamycin capsule, prednisone tablet, nystatin suspension, and M-dryl liquid.
Benefits for compounded Clindamycin capsule, prednisone tablet, nystatin suspension, and M-dryl liquid 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2020) provided on February 19, 2021. You asked the Plan to pay for eyeglasses. You say that you have always worn progressive lenses and feel that Medicare should reimburse you for the cost of standard lenses and frames. The Plan denied your request. The Plan says only standard frames are covered. The Plan also says any upgrades 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 covers these services when The Plan contract says covered eyeglasses after cataract surgery include standard frames and lenses. Upgrades such as progressive lenses are not a covered benefit. We looked at the file and the Plan's rules. The records show the Plan paid $140.57 towards the purchase of your frames, leaving a balance of $506.01. The progressive lenses which you purchased are not covered benefits of the Plan. Please note, the record indicates that the Plan has paid for the standard lenses and frames, you are responsible for the difference between the cost of the standard lenses and progressive lenses. Based on this information, we decided that the Plan's rules for coverage of eyeglasses and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2020) provided on February 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not 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 is not currently shown to be able or willing to perform out-of-bed activities. Better pain control is required to truly assess the enrollee's current level of function and needs. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET) scan, rest and pharmacologic stress.
You asked the Plan to pre-approve AQMBF PET scan rest and pharmacologic stress. 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. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve AQMBF PET scan rest and pharmacologic stress. Our reviewer says that the services are not medically necessary. Our physician reviewer found the plan requires that a cardiac single-photon emission computerized tomography (SPECT) must be suboptimal in quality or show equivocal results in order to provide an indication for PET. This has not occurred in this case. That said, the cardiologist has provided a compelling argument for the indication for a cardiac PET scan in this enrollee including the improved detection of multi vessel coronary disease and risk stratification for this enrollee. Thus, the rationale for the cardiac PET scan seems sound but the plan's criteria for the test are 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 AQMBF PET scan rest and pharmacologic stress have not been met. Therefore, we decided that the Plan does not have to pre-approve absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET) scan, rest and pharmacologic stress.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on February 27, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received urgent care services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 Urgently needed services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an urgent care visit on February 27, 2021. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the Urgently needed services 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 urgent care visit provided on February 27, 2021.
Your complaint about the experience you had with the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.