Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora physician home visit provided on June 20, 2019.You asked the Plan to pay forthe physician home visit. The Plan denied your request. The Plan says The Plan requires utilization of network providers when possible and available and requires authorization for certain services.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 did not pre-approve the servicesat 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 fora physician home visit provided on June 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora glucose monitor (E2100) and a lancing device (A4258) provided on June 12, 2019.You asked the Plan to pay fora glucose monitor and a lancing device. You say that these items should be covered.The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier.Therefore, we decided that the Plan does not have to pay fora glucose monitor (E2100) and a lancing device (A4258) provided on June 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe alveoloplasty provided on September 5, 2019.You asked the Plan to pay forthe alveoloplasty. You say that you told the dentist you only wanted what was covered by insurance. You say that you did not agree to the dentist billing for services that are not covered.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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe alveoloplasty provided on September 5, 2019.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan mustfollow 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 determineif the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee fell and injured his left hip on 1/15/20. X-ray revealed intertrochanteric fracture of the left hip and he underwent an open reduction internal fixation (ORIF) of the left hip with nail fixation on 1/17/20. Cardiology found an inferior and apical wall infarct without ischemia on a stress test before his surgery. Cardiology signed off for surgical clearance. He also needed insulin drip to control his elevated blood glucose and being acidotic. This resolved and the drop was stopped. His comorbid conditions include hypertension, myocardial infarct, coronary artery disease, and hyperlipidemia. Additionally, the enrollee has issues with constipation treated with medication. Prior level of function was independent. Currently the enrollee is weight-bearing as tolerated on left leg, able to ambulate 84 feet with rolling walker and minimal assist, transfers and bed mobility are at maximum assist, toileting/bathing/lower body dressing are at maximum assist and upper body dressing is at moderate assist. The complexity of the enrollee's nursing, medical and rehabilitation needsdo not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 15, 2019.You asked the Plan to pay forthe laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approvethe laboratory services.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 laboratory services provided on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the orthovisc injections provided from June 10 2019 through June 28, 2019.You asked the Plan to waive the coinsurance forthe injections. You say that the copayment is incorrect.The Plan denied your request. The Plan says that the coinsurance applied 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription 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 coinsurance forthe orthovisc injections provided from June 10 2019 through June 28, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 25, 2019.
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says you received a limited oral evaluation on February 7, 2018 by the same provider.
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 frequency limit of once per patient, per provider has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on August 16, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on August 16, 2019.
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 the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 12/20/19 for evaluationof failure to thrive and sepsis secondary to healthcare-associated pneumonia (HCAP) and urinary tract infection (UTI). Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care with ventilator support and weaning, seizure precautions, surveillance laboratory studies, intravenous antibiotics, foleycatheter care, and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 28, 2019 to August 31, 2019.
You asked the Plan to pay for physician services. You say that the Hospice benefits ended prior to the dates of service, so the plan should pay the claim. The Plan denied your request. The Plan says under Medicare guidelines Original Medicare is still responsible for payment until the start of the next month after revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 27, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 28, 2019 to August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), and the panoramic x-ray (D0330), provided on September 10, 2019.You asked the Plan to pay forthe dental services. You say that you did not know that the dentist was out of network. You also say that had you known that, you would not have gone there.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services received out of network are not covered.Medicare generally does notcover 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 and the services you received are listed as covered, they are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), and the panoramic x-ray (D0330), provided on September 10, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics should be a covered benefit.The Plan denied your request. ThePlan says this item is not a covered benefit.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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on October 30, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you cannot afford to pay for this service.The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.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, exams are limited to two procedures per plan year. The record shows that you received  limited oral evaluations on July 15, 2019 and October 3, 2019 and your exams benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower dentures (D5110, D5120). You asked the Plan to pre-approve the upper and lower dentures (D5110, D5120). You say that you need new dentures because your current dentures do not fit your mouth. You say you cannot eat. The Plan denied your request. The Plan says the services exceeds the maximum count allowed per period 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, there is a benefit limit for the upperand lower dentures (D5110, D5120). The plan clearly states that only one upper and lower denture procedure is covered every 5 years. The records show the Plan paid for one upper denture (D5110) and one lower denture (D5120) procedure on January 11, 2017, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approvethe upper and lower dentures (D5110, D5120)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve Xidra eye drops.You asked the Plan to pre-approve the Xidra eye drops. You say that the member has been using Xidra eye drops since 2018 and has had positive feedback with the drops. The Plan denied your request. The Plan says the eye drops should be processed under Medicare Part D, not Medicare 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 notamong the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xidra eye drops. Benefits for the Xidra eye drops may be available under Medicare Part D.Contactthe 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 the problem focused limited oral evaluation (D0140) and adjustment of complete maxillary denture (D5410) provided on August 23, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation and denture adjustments. You say that you called 2 in-network facilities to schedule an appointment and they denied you the services. You also say that all of the providers that are in-network will not touch the repair work if they did not do the original work for the dentures.The Plan denied your request. The Plan says that these services are not covered by the Plan.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 forthe problem focused limited oral evaluation (D0140) and adjustment of complete maxillary denture (D5410) provided on August 23, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation or inpatient care (99236) provided on July 13, 2019.You asked the Plan to pay for observation or inpatient care. You say that you are appealing the claim with the medical records and the denied EOB and request reconsiderationThe Plan denied your request. The Plan says this service exceeds the maximum number allowed per day. Another observation service was reported for the same date of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, observation care may only be reported by the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care. Payment for observation care codes is for all the care rendered by the ordering physician on the date(s) the patient is in an observation status and may only be reported once per day. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must report the appropriate outpatient service codes. based on this information, we decided that Medicare rules for coverage of observation or inpatient care have not been met.Therefore, we decided that the Plan does not have to pay forobservation or inpatient care (99236) provided on July 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia for the enrollee.You asked the Plan to pre-approveProlia. You say that this is medically necessary.The Plan denied your request. The Plan says that there are no records supporting enrollee has tried one oral bisphosphonate.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed an oral bisphosphonate and zoledronic acid or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia (D9241), extraction (D7140) of tooth # 26, the bone replacement graft (D4263), repair of maxillofacial defect (D7955), biologic materials to aid in tissue regeneration (D4265 x 2), the periodontal scaling and root planing (D4341) for all 4 quadrants, and the guided tissue regeneration (D4266 x 2) provided on July 10, 2019.You asked the Plan to pay forthe dental services. You say that you have an infection in the lower, front of your mouth. You say that the infection has eaten away at the bone. You also say that this should be reviewed as medical.The Plan denied your request. The Plan says the annual dental allowance of $200 has been reached.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 annual dental allowance of $200 has been reached. The record shows the Plan paid $85.50 for services received from January 9, 2019 to January 18, 2019 and $114.40 for services you received from June 5, 2019 to July 10, 2019.Therefore, we decided that the Plan does not have to pay forthe anesthesia (D9241),extraction (D7140) of tooth # 26, the bone replacement graft (D4263), repair of maxillofacial defect (D7955), biologic materials to aid in tissue regeneration (D4265 x 2), the periodontal scaling and root planing (D4341) for all 4 quadrants, and the guided tissue regeneration (D4266 x 2) provided on July 10, 2019.