Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for ophthalmological medical exam and evaluation (92004). We decided that the Plan does not have to pay for refraction services (92015).
You asked the Plan to pay for ophthalmological medical exam and evaluation (92004). You say that you have always had coverage for this same service in the past years and this is the first time you was denied. The Plan says that the vision services is not covered by the plan.
We decided that the Plan has to pay for ophthalmological medical exam and evaluation (92004).
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 services were provided by an in-network Ophthalmologist. The Plan contract says that there is a 4% coinsurance for each specialist's office visit. Therefore, we decided that the Plan has to pay for ophthalmological medical exam and evaluation (92004).
We also decided that the Plan does not have to pay for refraction services (92015).
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 for refraction services. Therefore, we decided that the Plan does not have to pay for refraction services (92015).
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: Favorable

We decided that the Plan has to pay for the SNF care provided from July 18, 2019 to August 16, 2019.You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says that the enrollee did not require any skilled services or care that could not have been provided in an alternate setting other than a SNF.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 pay for SNF care. Our reviewer says that the enrollee meets the Medicare criteria forSNF care. Our physician reviewer found the enrollee did have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pay for the SNF care provided from July 18, 2019 to August 16, 2019.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin fillings on teeth coded as D2393 and D2394 provided October 23, 2019 to November 1, 2019.You asked the Plan to pay forthe dental service. You say that you had trouble eating and all of the dentists had a 2 months waiting list and this provider fixed the problem on the same day you went to see him.The Plan denied your request. The Plan says the service provided is not a covered under the plan benefits.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. Services not listed on the Medical Benefits Chart is not covered by the plan.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 forresin fillings on teeth coded as D2393 and D2394 provided October 23, 2019 to November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance transport provided on August 24, 2019.
You asked the Plan to waive the cost share for the ambulance transport. You say that you have no control over which ambulance service takes you to the hospital. You say that you are appealing the out-of-network service. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Your contract with the Plan says that after your yearly deductible is met, you pay $100 for each one-way Medicare-covered ambulance transport. The item or service you asked the Plan to waive the cost share for falls within the "Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to ambulance services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on August 24, 2019. Therefore, $300 was applied to the deductible.
Since your $300 deductible was met, you have also been asked to pay a $100 copayment for the ambulance transport. The records show that the in-network deductible was applied. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the ambulance transport provided on August 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 2/11/20 for shortness of breath with decline in mental status. She was diagnosed with acute hypoxic respiratory failure and acute metabolic encephalopathy. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for not reaching her maximum functional ability.The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings such as a skilled nursing facility, home with home health and home physical therapy or home with outpatient therapy.The Plan must follow 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 determine if the Plan was correct in denying the requestto pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is currently in an outpatient setting and does not require an acute hospital level of care. She is ambulating greater than household distances and is performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF level.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF 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 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 determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided at a skilled nursing facility (SNF) level. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted with syncope and diagnosed with carotid stenosis. He underwent cardiac catheterization and stenting. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) 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: 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. The Plan denied your request. The Plan says that skilled nursing and or skilled therapy services do not need to be provided daily in an inpatient facility on a daily basis.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 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on September 5, 2019.You asked the Plan to pay for the chest x-ray provided. 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 enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on September 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the drug has been approved under the enrollee's Part D benefits for 6 months.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Retacrit
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral radiofrequency ablation (RFA) of the facet joints.You asked the Plan to pre-approve the RFA procedure. You say that these have been covered in the past and should be approved.The Plan denied your request. The Plan says only one single positive MBB has been done. Other injections previously provided do not count toward the two required positive MBBs.The Plan must follow Medicare rules. Medicare rules say that RFA of the facet joints is covered only after two positive MBBs which provide 80% pain relief. Only a single MBB is documented as being done in the record.Therefore, we decided that the Plan does not have to pre-approve a bilateral radiofrequency ablation (RFA) of the facet joints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe specialist office visit provided on September 17, 2019.You asked the Plan to reduce the copayment forthe specialist office visit. You say that the provider and the health Plan representative assured you that the provider was in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for out-of-network physician specialist services (including surgery second opinion and telehealth or urgently needed services). You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network.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 reduce the copayment forthe specialist office visit provided on September 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin filling (D2392) and intraoral periapical first x-ray (D0220) provided October 28, 2019.You asked the Plan to pay forthe dental services. You say that your dental bills have been denied and you do not know why. Your advantage plan has vision and dental benefits.The Plandenied your request. The Plan says the requested services are not covered under the plan benefits.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. Services not listed under the Description of Benefits is not covered by the plan.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 forresin filling (D2392) and intraoral periapical first x-ray (D0220) provided October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (romosozumab).
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your request. The Plan says enrollees must try plan preferred drugs such as risedronate, ibandronate, and zoledronic acid before alternatives can be considered.
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 Evenity. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there was no trial of the plan preferred drugs and no documented reason in the records why the enrollee cannot use the plan preferred medications. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity (romosozumab).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that there is not skilled nursing facility that can handle the enrollee's peritoneal dialysis. The Plan denied your request. The Plan says the treatment you need can be provided in a lower level of care such as a skilled nursing facility or home with home health care.
The Plan must follow 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 determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee 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-approve acute inpatient rehabilitation facility (IRF) admission and services.