Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020), bifocal lens (V2200) and progressive lens (V2781).

You asked the Plan to pay for the eyewear. You say that you thought that you were eligible for new glasses again because you had gotten your last pair in the same month two years ago and did not realize that the specific date of service mattered as well. You also state that while these were ordered, you did not actually receive and pay for them. The Plan denied your request. The Plan says you last exhausted your vision benefits, which means you were not eligible for new glasses under your benefits. The claim was submitted to the Plan with the order date as the date of service, which is prior to the date you became eligible again. In addition, progressives and other lens options are not a covered benefit.

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 will grant a $200 vision allowance every two years for routine eyewear. This benefit is administered on a rolling calendar year since your last date of service. Additionally, eyewear does not include lens options, such as tints, progressives, transition lenses, polish, and insurance.

We looked at the file and the Plan's rules. The record shows that you last received and exhausted your vision benefits less than two years from the last date of service. In addition, the Plan's contract clearly states that they do not cover lens options, such as progressives. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), bifocal lens (V2200) and progressive lens (V2781).

Your complaint about the date of service being reflected as the order date rather than the date you were actually provided the eyewear 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the office visit you had on November 23, 
2020. 
 
You asked the Plan to adjust the copayment. You say that this should be a PCP copayment. The Plan denied 
your request. The Plan says you are responsible for the applied cost share. 
 
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 $35 
copayment for each specialist visit.  
 
Review of the file shows that you had a specialist visit on November 23, 2020. You have been asked to pay a 
$35 copayment for the office visit. The visit falls within the physician 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 adjust the copayment for the office visit you had on November 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo solution 240mg/24ml 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 medical studies have not proven that this drug is helpful when a similar drug was tried 
without a positive response. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the review has 
determined that the documentation does not support that the Opdivo is medically reasonable and necessary for 
the enrollee. The clinical value and effectiveness of Opdivo in the setting of disease progression following prior 
PD-1/PD-L1 treatment (Keytruda) have not been demonstrated. The documentation does not support that the 
Opdivo is safe and effective for 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo solution 240mg/24ml for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (CPT 93971) provided to the enrollee on 
September 24, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a procedural modifier is required per Medicare guidelines. 
 
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, the CPT Code Manual definition of code 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers." 
 
We asked our coding 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found when 
patients are in a Skilled Nursing Facility (SNF) Medicare pays for the services provided to its beneficiaries 
under Part A, including most provided by outside entities such as imaging centers. Payment would be included 
in a bundled prospective payment made to the SNF. The imaging center must bill its technical component fee 
to the SNF and send its separate professional component bill to the Medicare plan. Therefore, this service 
requires an appropriate modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for imaging services (CPT 93971) provided to the enrollee on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the orthoses. You say that you are attaching documentation which supports the fact that the enrollee was treated by the physician. The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim. The records show that the evaluation did not take place at a qualifying originating site.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) for the date of 
service October 9, 2019. 
 
You asked the Plan to pay for the automatic defibrillator. You say that the was a billing error. The Plan denied 
your request. The Plan says there is a claim paid for the same date of service by the same provider. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The record shows the claim for October 9, 2019 was paid to the same provider, 
therefor the additional claim will not be paid.  
 
 Therefore, we decided that the Plan does not have to pay for an automatic external defibrillator (K0606) for 
the date of service October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings for teeth # 8, 9, and 13 provided on October 12, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you asked several times how much it would cost 
and if they were covered. You say that you were not told how much you would have to pay. You say that you 
would not have had the fillings done if you knew that they would not be covered. You say that you are willing 
to pay for part of the treatment. You also say that this bill is much more than you should afford. The Plan 
denied your request. The Plan says fillings are not listed as covered services. 
 
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 the base dental benefit. Therefore, we decided that the Plan does not have to pay 
for the fillings for teeth # 8, 9, and 13 provided on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric treatment to begin on 
April 6, 2021. 
 
You asked the Plan to pre-approve additional inpatient psychiatric treatment. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 additional inpatient psychiatric 
treatment. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee was not showing any dangerousness to self 
or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of safety. The enrollee was cooperative and compliant. The Ativan medication was discontinued on 
April 2, 2021. The enrollee was not going through any withdrawals. Therefore, the enrollee does not meet 
criteria for the requested additional inpatient 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 additional inpatient psychiatric treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional inpatient psychiatric treatment to begin on April 
6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on November 6, 
2020. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that you could not get x-rays done in 
the primary care office because they were ordered for surgery. You say that you should not be penalized with 
this copayment. The Plan denied your request. The Plan says the copayment 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 a $0 
copayment for Medicare-covered x-rays at your PCP's office. $85 copayment at all other locations (including 
separate facilities in the same building as PCP office). 
 
You have been asked to pay $73.63, which is less than the standard $85 copayment for the chest x-ray. The 
chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
There is no provision in the contract which indicates a copayment would be waived for a service performed for 
a surgical procedure. 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 chest x-ray provided on 
November 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested services are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested services are not medically necessary.

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 that you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You can continue to received skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat-lift mechanism, power scooter, and sitz bath chair (E0627, E1230, E0162).

You asked the Plan to pre-approve the items. You say that these items are medically necessary. The Plan denied your request. The Plan says the documentation does not support that the items are medically necessary.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. No medical records or documentation was provided to support that these items were medically necessary or that Medicare rules for coverage are met. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat-lift mechanism, power scooter, and sitz bath chair (E0627, E1230, E0162).
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's chances to return home and maintain living at home will be significantly reduced if the opportunity to participate in an acute rehab program is denied. The Plan denied your request. The Plan says the therapy required is not therapy that is uniquely provided in the IRF.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for mental status changes, urinary tract infection, and rhabdomylosis after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs expanded services at the IRF. The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section. 

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 that, based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 

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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gel-One

You asked the Plan to pre-approve Gel-One. You say that you would like reconsideration because this service is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says that there no record of a trial of physical therapy or other treatments.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Gel-One. Our reviewer says that the member meets Medicare criteria for coverage of this service. Our physician reviewer found the narrative from the office visit note describes years of knee symptoms and prior trials of analgesics and physical therapy. A letter from the provider further supports this and physical therapy notes document at least 13 visits with physical therapy for knee pain and functional impairment related to the arthritis. The provider has documented in the office visit note that a corticosteroid injection into the knee joint is not a good idea for this particular enrollee with multiple comorbidities.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have been met. Therefore, we decided that the Plan has to pre-approve Gel-One.

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission for a left total knee arthroplasty 
for the enrollee. 
 
You asked the Plan to pre-approve inpatient level of care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is approved for outpatient surgery. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 level of care. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request for inpatient admission for left total knee arthroplasty is not medically 
reasonable or necessary. Detailed documentation is not evident regarding active co-morbidities that would 
require presumptive approval for an inpatient stay. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the request for inpatient admission for left total knee arthroplasty is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission for a left total knee arthroplasty for the enrollee.