Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance provided on April 17, 2021.

You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (K0553). You
say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee confirmed the
supplies were not ordered and she was cold called.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the supply allowance for therapeutic continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance provided on April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services (annual wellness visit) provided on May 6, 2021.

You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management services. You say that you wanted to have this exam done before you returned at the end of May 2021. The Plan denied your request. The Plan says the services received exceed your benefit limit.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services (annual wellness visit) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit (99213) provided on
February 22, 2021.

You asked the Plan to reduce the copayment for the office visit. You say that this was a routine exam and
should only have a $20 copayment. The Plan denied your request. The Plan says this copayment was assessed
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 $35
copayment for an office visit with a specialist.

You have been asked to pay a $35 copayment for the office visit. You feel that you should only pay the $20 copayment for a routine eye exam. A routine eye exam is performed to determine if there are changes in your vision which would require eyeglasses. The eye exam provided on February 22, 2021, was performed by an ophthalmologist and was billed with medical diagnoses, which is not the same as a routine eye exam. An ophthalmologist is a type of specialist, and the service billed in this case is an office visit. 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 for the office visit (99213) provided on February 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says you are no longer a threat to yourself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services beyond August 30, 20201, were requested. 

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 services. Our physician reviewer found that active treatment was not taking place beyond the date in question. The services were not reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.

Based upon review the records, you could be treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions, and was not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to safety. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided by participating providers on March 12, 2021, to on May 6, 2021.

You asked the Plan to waive the copayment for an urgent care visit. You say that these were for Covid-19 tests. You say that you do not think you should have to pay for this. 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 $60 copayment for urgently needed services. 

You have been asked to pay a $60 copayment for each urgent care visit. The total amount you are being asked to pay is $120 ($60 x 2 visits = $120). The correct copayments have been applied to the services that were provided. An urgent care visit falls within the urgently needed 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 an urgent care visit provided by participating providers on March 12, 2021, to on May 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you cannot get up from sitting without significant physical assistance, and you cannot go up steps on your own. You also say that you do not have someone at home who can physically assist you. The Plan denied your request. The Plan says the enrollee has no medical or therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 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. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Artacent wound graft (CPT code(s): Q4169 and 15275), for the enrollee.
You asked the Plan to pre-approve the Artacent wound graft. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee's condition does not meet the rules for approval because the enrollee does not have any approved indication for stem cell therapy (amniotic cell therapy).
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 Artacent wound graft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a non-pressure diabetic ulcer of the left foot. The record indicates that the enrollee developed an infection at the end of July 2021. The record indicates that the wound is improving with conservative wound therapy.
The record provided does not indicate the use of the requested service. The record provided does not support the medical necessity or reasonableness of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Artacent wound graft have not been met. Therefore, we decided that the Plan does not have to pre-approve the Artacent wound graft (CPT code(s): Q4169 and 15275), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
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 a Group 3 PWC is covered when specific criteria are met. 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 criteria for coverage are not met. Our physician reviewer found the enrollee has a mobility deficit that impairs mobility-related activities of daily living (MRADLs) in the home and it is not helped by the use of a walker, cane, or manual wheelchair due to contractures and weakness. While she may be able to safely operate a PWC, the requested Group 3 PWC with multiple power options exceeds her medical needs. The documentation does not reveal that she is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). Her strength and functional ability with independence in eating and grooming should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary therefore the request for Group 3 power wheelchair with multiple power options 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on April 5, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges because you have never been charged for an MRI in the past. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged he correct amount.
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 $150 copayment for radiological diagnostic services.
You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 MRI provided on April 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare does not provide for daily skilled services due to a fall without injury.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the current level of function and ability to tolerate therapies, the member does not require daily skilled therapies in an inpatient 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electronic connection between two systems (E2311).
You asked the Plan to pre-approve the electronic connection. You say that you would like reconsideration because the requested accessory is medically necessary. The Plan denied your request. The Plan says you do not have a medical need to control 3 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. 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 electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Your strength and function in the upper extremities with the ability to feed independently supports that you can control any power options through your own individual switches. 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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection between two systems (E2311).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication that the preferred agents would likely be less effective and/or have adverse effects.
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 services. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc is not approved as step criteria is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia Sol 60mg/ml.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication is not given or supervised by the physician and is not supplied by the physician (not buy and bill).
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 Prolia Sol 60mg/ml.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a sleep positioner and a chest belt provided on December 18, 2020.
You asked the Plan to reimburse you for a sleep positioner and a chest belt purchased from a non-certified supplier. You say that that the Plan should reimburse you. The Plan denied your request. The Plan says you purchased these items form a non-participating supplier.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. To receive payment for covered Medicare items or services a provider or supplier must be enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of a sleep positioner and a chest belt purchased from a non-certified supplier have not been met. Therefore, we decided that the Plan does not have to reimburse you for a sleep positioner and a chest belt provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the eye exam to be provided by an OON provider.
You asked the Plan to pre-approve the eye exam. You say that the in-network provider does not specialize treating patients with eye problems due to down syndrome. The Plan denied your request. The Plan says the provider is out-of-network
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the eye exam to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says your condition has improved.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services were requested from August 16, 2021, forward. 

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 services. Our physician reviewer found that it did not appear that active treatment was taking place. The services were not reasonably expected to improve your condition or for the purpose of diagnosis. You were treated under an individualized treatment plan found in the record.

Based upon review the records provided, you do not meet the criteria for continued acute inpatient mental health treatment. You were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations. You were cooperative/compliant with treatment while not showing any threats the safety. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.