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

We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.
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 SNF admission. You say that it is felt that SNF care is needed. The Plan denied your request. The Plan says there is no documented need for daily skilled services.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is a 90-year-old female with a past medical history including diabetes mellitus, hypertension and metastatic breast cancer who was admitted to the hospital due to weakness and poor appetite and found to have a gastrointestinal bleed and an infection with COVID-19 virus. She stabilized medically and was admitted to a skilled nursing facility for further isolation. She has not required any skilled nursing services and has been receiving therapy services via telehealth. Additionally, she has intermittently refused to worker with therapy services. At the time of transfer into the skilled nursing facility for isolation the member was medically stable. She did not require any supplemental oxygen or medications specific for infection with COVID-19. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. The member was noted to be at or near her functional and medical baseline. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says there are in-network providers available for these 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen 10,000 units/ml vial for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the step therapy guidelines were not followed.
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 the drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has anemia from chronic renal disease. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen 10,000 units/ml vial for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided January 19, 2021.
You asked the Plan to pay for the complete upper and lower dentures. You say that you would like the services covered. The Plan denied your request. The Plan says the services are not covered because the provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care. We looked at 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 complete upper and lower dentures have not been met. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided January 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90832) provided December 3, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 90832 is not supported in the medical record. Specifically, the provided records do not show that the services were provided on order from or in consultation with the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90832) provided December 3, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued weekly home skilled nursing visits beyond August 12, 2021.
You asked the Plan to pre-approve the continued home health services. You say that the enrollee requires these weekly visits for medication administration services. The Plan denied your request. The Plan says that there is no longer a need for a skilled nurse to provide these services.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued weekly home skilled nursing visits beyond August 12, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition does not require skilled nursing care as an inpatient.
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 the requested services are not medically reasonable or necessary. Our physician reviewer found as of August 28, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care, as of August 28, 2021. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, spandex over spacer mesh cover (K0108), push handle (K0108) knee pads (K0108) and wheelchair accessory, power seat elevation system (E2300)
You asked the Plan to pre-approve the power wheelchair accessories. You say that you are appealing the denial of coverage because you believe the power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the spandex over spacer mesh cover is a convenience item. The push
handles and knee pads are non-standard upgrades and do not serve a medical purpose. The power seat elevation system does not serve a medical purpose.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair component or accessory, spandex over spacer mesh cover (K0108), push handle (K0108) knee pads (K0108) and wheelchair accessory, power seat elevation system (E2300)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP cleaner.

You asked the Plan to pre-approve the item. You say that you need this to keep your CPAP clean and sanitary. The Plan denied your request. The Plan says the item is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve CPAP cleaner.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an outpatient surgery. You say that you do not want to have heart surgery with a doctor you do not know. The Plan denied your request. The Plan says there are in-network physicians available to provide these 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 22, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 October 21, 2020. 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's services provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a
participating provider on February 5, 2021.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that this was because of your
second Covid-19 vaccine shot. You say that you would like the Plan to pay this. The Plan denied your request.
The Plan says the correct coinsurance 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 20%
coinsurance for outpatient surgery/outpatient hospital.
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total
allowed amount is $15,334.37. The 20% coinsurance is $3,066.87 ($15,334.37 x 20% = $3,066.87). You are
being asked to pay $2,585.56 due to your out-of-pocket maximum being met. An outpatient surgery falls within
the outpatient surgery/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 coinsurance
for an outpatient surgery provided by a participating provider on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visits (99205, 99215) to be provided by an out of network provider for low vision aids.
You asked the Plan to pre-approve the office visit. You say that it is too far to travel to other providers and this doctor is closer. You have puckering of macula, right eye and benign neoplasm of right choroid. You are also
deaf and is very worried to lose your eyesight. The Plan denied your request. The Plan says low vision aids are not covered by the Plan.
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 does not cover low vision aids under any condition. We looked at the file and the Plan's rules. The health plan contract says that radial keratotomy, LASIK surgery, and other low vision aids is not covered under any condition. Based on this information, we decided that the Plan's rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visits (99205, 99215) to be provided by an out of network provider for low vision aids.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Grafix Prime skin substitute for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the wound originated as a pressure wound.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. W

e 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the skin substitute is reasonable and necessary to avoid surgery and amputation. 

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 services have been met. Therefore, we decided that the Plan has to pre-approve Grafix Prime skin substitute for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that you want a power wheelchair to enjoy
more freedom when going out with family to the park, shopping etc. The Plan denied your request. The Plan
says you are requesting the PMD for outside the home and the evaluation states your mobility limitation can
sufficiently and safely be resolved by the use of a heavy-duty manual wheelchair.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

The rules also state that for equipment to be covered, it must be appropriate and needed for use inside the
home.

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your
condition can be improved by a walker, cane or manual wheelchair. The item at issue in this appeal is being
requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers
PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been
met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99203).
You asked the Plan to pre-approve the office visit. You say that the services should be covered because there are no chiropractors within your area. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99203).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair component or accessory, transit kit
option (K0108).
You asked the Plan to pre-approve transit kit option. You say that the medical records provided will show proof
of medical necessity. The Plan denied your request. The Plan says transit option is a non-medical feature that is
intended for use outside the home. This item is not considered DME and is not statutorily covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of transit kit option have not been met. Therefore, we decided that the Plan does not have to preapprove
the wheelchair component or accessory, transit kit option (K0108).