Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the SNF stay. We decided that the Plan does not have to waive the copayment for the SNF stay. You asked the Plan to waive the copayment for the SNF stay. You submitted your bill for review. You say that the issue should be reconciled.The Plan says that the copayment applied correctly.We decided that the Plan has to waive the copayment for the SNF stay. The records show that only 19 SNF days should be charged the $100 copayment in November. Therefore, we decided that the Plan has to reduce the copayment for the SNF stayfrom $2,210 to $1,900. We also decided that the Plandoes not have to waive the copayment for the SNF stay.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 per day for days 1-20 and a $100 copayment per day fordays 21-100for the SNF stay.Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay.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 skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment in a SNF. There are no complex wounds, new enteral feedings, IV antibiotics or other skilled nursing (SN) level needs. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The skilled services are not needed on a "daily basis" in a SNF. As a practical matter you do 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) 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 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 (E0676).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided from October 1, 2019 to
October 30, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says
These services do not fall within the exception of emergency or urgently needed services and a prior
authorization is required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 nurse practitioner services provided from October 1, 2019 to
October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 27, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.
You asked the Plan to pre-approve the Supartz FX. You say that Supartz FX is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required 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 the Supartz FX. 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 reason why they would be contraindicated for this 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 Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 21, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921) and scaling (D4346) provided on January 16, 2020.
You asked the Plan to pay for gingival irrigation and scaling. You say that you believed dental services were covered. The Plan denied your request. The Plan says these services are not covered under your dental 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 gingival irrigation (D4921) and scaling (D4346) provided on January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on December 11, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 17313 is not supported.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 17313 is a micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, colorcoding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks.We find that CPT code 17313 is not supported in the medical record. Specifically, there is no documentation of microscopic findings of surgery for the billed date of service. 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 pay forthe surgical services rendered on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on December 11, 2019.
You asked the Plan to pay for the wound care services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from July 12, 2019 through January 9, 2020 and from January 15, 2020 through February 16, 2020. The Plan says, per Medicare guidelines, the provider needs to bill Original Medicare for the services rendered on December 11, 2019.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the wound care services provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction (90215) provided by a provider who is out-of-network on November 21, 2019.You asked the Plan to pay for refraction. You say that this should be covered.The Plan denied your request. The Plan says this claim must be submitted to in network provider.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 coverage rules state that you are responsible for submitting a Vision Care out-of-network claim form with itemized receipt when seeing a Select provider.We looked at the file and the Plan's rules. The record does not show that you have submitted a claim as required by Plan rules. Based on this information, we decided that the Plan's rules for coverage of refraction have not been met.Therefore, we decided that the Plan does not have to pay for refraction (90215) provided by a provider who is out-of-network on November 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322) 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 their preferred visco supplements are Orthovisc and Monovisc and don't require prior authorization.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 drug is not medically reasonable or necessary. Our physician reviewer found the records do not indicate a trial and failure of the required drugs. There is no indication that the plan's required drugs would likely be less effective and/or have adverse effects 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 Hymovis (J7322) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aransep.
You asked the Plan to pre-approve Aransep. You say that Aransep is medically necessary. The Plan denied
your request. The Plan says a trial of Retacrit is required before Aransep 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 Aransep. Our reviewer says that
coverage criteria has not been met. Our physician reviewer found the record does not show any reason why the
enrollee cannot use the plan preferred drugs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aransep have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aransep.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 3, 2020.You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received office visit services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $5 copayment for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received an office visit on the morning of January 3, 2020. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the Physician/Practitioner 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 waive the copayment for the office visit provided on January 3, 2020.Your complaint about not being present in the office on the date of service in dispute 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vasectomy (55250).
You asked the Plan to pre-approve this procedure. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that a Vasectomy is not a covered benefit for elective sterilization.
The Plan must follow Medicare rules. Medicare rules say that a Vasectomy is not covered if the primary indication for this procedure is sterilization. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this procedure have not been met. Specifically, the primary indication for this procedure is sterilization. Therefore, we decided that the Plan does not have to pre-approve a Vasectomy (55250).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) 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 step therapy criteria have not been met.
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 does not meet the step therapy requirements. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drug - zoledronic acid. The provided medical records do not indicate that the plan's required drug would likely be less effective and/or likely have adverse effects 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 Prolia (J0897) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable controller, expandable controller harness, electronic connection and push handles.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.  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 an expandable controller, expandable controller harness and electronic connection. Our reviewer says that an expandable controller, expandable controller harness and electronic connection are not considered medically reasonable and necessary in this case. The medical records provided do not support that these items are medically reasonable and necessary. Ourphysician reviewer found that the enrollee's condition does not meet criteria for an expandable controller, expandable controller harness and electronic connection.The push handlesat issue in this appeal do not serve a purpose that is primarily medicalin nature. This item is available to the general public and would be helpful even to those who are not sick or injured.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-approvean expandable controller, expandable controller harness, electronic connection and push handles.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient cancer treatment provided from June 10, 2019 to July 2, 2019. 
 
You asked the Plan to pay for outpatient cancer treatment in Cancun, Mexico. You say that you should be reimbursed for these services. The Plan denied your request. The Plan says non-emergent services provided outside of the United States are not covered by Medicare or the Plan. 
 
Medicare rules say that services received outside of the United States are not covered. The Plan follows the same rule with the exception of urgent and emergent services. 
 
The record shows that the outpatient cancer treatment at issue were received outside of the USA. These services were not emergent or unforeseen. This means that the services are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of outpatient cancer treatment in Cancun, Mexico have not been met. Therefore, we decided that the Plan does not have to pay for outpatient cancer treatment provided from June 10, 2019 to July 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an incisional biopsy of oral tissue (D7286) and a consultation, including oral evaluation (D9310) provided on September 25, 2019.
You asked the Plan to pay for the dental services. You say that you saw the provider for an oral biopsy. You say that a plan representative advised that because the procedure was surgical, you should be covered at 80%. The Plan denied your request. The Plan says the services you received were medical in nature.
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 dental services are not among those covered under this benefit. Additionally, the case file does not demonstrate that the services which were billed fall within the Medicare-covered non-routine dental services guidelines. Therefore, we decided that the Plan does not have to pay for an incisional biopsy of oral tissue (D7286) and a consultation, including oral evaluation (D9310) provided on September 25, 2019.