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

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on January 26, 2021.

You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were never told how much the chair would cost. 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 durable medical equipment. 

You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $357.89. The total amount you are being asked to pay is $71.58 ($357.89 x 20% =
$71.58). The correct coinsurance has been applied to the equipment that was provided. Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on January 26, 2021.
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 requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the
requested level of care is not medically necessary.
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that the 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on March 17, 2021, to March 20, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you thought that if you went back to the emergency room for the same problem then you would not have to pay another copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care.
You have been asked to pay a $90 copayment for an emergency room visit. The total amount you are being asked to pay is $180 ($90 x 2 emergency room visits = $180). An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on March 17, 2021, to March 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device appliance provided on January 25, 2021.

You asked the Plan to pay for a segmental gradient pressure pneumatic appliance, half leg (E0673). You say that the appliance was medically necessary. The Plan denied your request. The Plan says the device and supplies are not covered by Medicare to prevent deep vein thrombosis during or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD appliance have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device appliance provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (PPE) (D1999) provided on September 3, 2020.

You asked the Plan to pay for the PPE. You say that you were assigned this provider by the Plan. You say that you were not aware that this provider had opted out of Medicare. You also say that you received a bill for $319.

The Plan denied your request. The Plan says personal protective equipment (PPE) is not reimbursable under the supplemental 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 for the personal protective equipment (PPE) (D1999) provided on September 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional ModivCare mileage for routine transportation.

You asked the Plan to pre-approve the additional mileage. You say that the additional mileage The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee exceeds the limits set in the subscriber agreement.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles one-way. 

22 extra miles are being requested for non-emergent transportation. This is not allowed by the contract. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional ModivCare mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).

You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit 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 pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 22, 2020 by an
out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician.
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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue.
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that
the Plan does not have to pay for physician services provided on December 22, 2020 by an out-of-network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 23, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you were unaware that you would have any charges for that. 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 Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $4,247. The total amount you are being asked to pay is $849.40 ($4,247 x 20% = $849.40). An
injection falls 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 for an injection provided by a participating provider on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro G Motion orthotic device.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of a head injury with left upper extremity hemiparesis. Current guidelines designate robotic therapy to be of uncertain utility compared with dose-matched conventional upper limb exercise therapies. The MyoPro Motion G device is considered experimental/investigational in nature and 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 these services have not been met.

Therefore, we decided that the Plan does not have to pre-approve a MyoPro G Motion orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).

You asked the Plan to pre-approve the mandibular partial denture. You say that you need your lower denture fixed. The Plan denied your request. The Plan says this service 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, mandibular partial denture (D5226) is limited to one procedure every five plan years. The record shows that you received a mandibular partial denture (D5226) on May 11, 2020 and your mandibular partial denture (D5226) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the extractions. You say that the oral surgeon wants $400 per tooth, but you are on a fixed income and unable to afford the cost of the extractions. The Plan denied your request. The Plan says dental services are only covered by the Plan when they are performed by a participating general dentist. The Plan also says that services performed by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve twelve extractions to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on February 12, 2021.
You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because the providers at issue have different specialties. The Plan denied your request. The Plan says both physicians are specialists in Internal Medicine, and both participate in the same group practice under the same Tax ID number.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. the rules also say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. We find that CPT code 99223 is not supported in the record. Specifically, the documentation submitted shows that CPT code 99223 was billed on the same date of service by providers in the same group with the same specialty. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on February 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan Drops
You asked the Plan to pre-approve the Zioptan Drops. You say that Zioptan has been adequately controlling of the enrollee's inraocular pressure. You also say that it is pertinent that the enrollee remains on the Zioptan to prevent further vision loss. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan Drops
Benefits for the Zioptan Drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of a HHA (G0156) for 8 hours per day, 56 hours per week.

You asked the Plan to pre-approve the HHA services. You say that you are not getting better and need more help. You also say that your walking and breathing are getting worse, and the nurses and doctors feel the same. The Plan denied your request. The Plan says there is no evidence that you need HHA care 8 hours per day to help out. The Plan also says that the total amount of time needed to help you is 5 hours per day.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 HHA services. Our reviewer says that the additional hours of HHA services are not medically reasonable and necessary. Our physician reviewer found you are receiving palliative services for lung cancer. Our reviewer found that you are not shown to require eight hours per day of HHA services in order to address medical issues. Our physician reviewer also found that the Plan's reduction in coverage is reasonable. 

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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve services of a HHA (G0156) for 8 hours per day, 56 hours per week.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network on February 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at 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 for the services provided by an out-of-network on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral device to treat obstructive sleep apnea.
You asked the Plan to pre-approve the oral device. You say that you would like reconsideration because the member should not have to travel for treatment. The Plan denied your request. The Plan says the documentation does not show that there is an intolerance to continuous positive airway pressure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 oral device. Our reviewer says that the member presented with a sleep study indicating an AHI of 12.8. The daytime Epworth sleepiness score was noted as being 3, a normal score. There is no noted history of hypertension, ischemic heart disease or stroke. Our physician reviewer found there is no documentation from a physician that supports the criteria requiring a showing of excessive sleepiness, impaired cognition, mood disorder or insomnia or of hypertension, ischemic heart disease or stroke. Given the specific requirements for the Obstructive Sleep Apnea appliance, there would not be necessity for the appliance given the documentation as provided. 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 oral device have not been met. Therefore, we decided that the Plan does not have to pre-approve the oral device to treat obstructive sleep apnea.