Persius/hicric huggingface dataset:
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 SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF 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 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 no identifiable skilled nursing service needs. You do have identifiable skilled therapy service needs; however, you do not require skilled therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) additional PT visits.
You asked the Plan to pre-approve seven (7) additional PT visits. You say that seven (7) additional PT visits are medically necessary. The Plan denied your request. The Plan says seven (7) additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 seven (7) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have plateaued with therapy with no real improvement in pain or function. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Follow up with orthopedics appears appropriate at this point for further evaluation and treatment. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seven (7) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven (7) additional PT visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.

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 a maximum of 52 one-way transportation trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lenses.

You asked the Plan to pre-approve progressive lenses. You say that the items are necessary. The Plan denied your request. The Plan says the requested items 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 covers clear plastic single-vision, lined bifocal, trifocal or lenticular lenses.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve progressive lenses.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that this procedure is medically necessary and the
most effective treatment for the enrollee. The Plan denied your request. The Plan says that the clinical value
and effectiveness of the Intracept procedure in the setting of chronic low back pain and lumbosacral
radiculopathy has not been demonstrated in the peer-reviewed literature.
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 requested services are not considered medically reasonable and necessary in this case. The Intracept
procedure remains experimental for the treatment of back pain. More research is needed to show safety and
efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the total knee arthroplasty (27447), the physical therapy evaluation (97161), and the occupational therapy evaluation (97165) provided from October 20, 2020, through October 21, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $360 copayment for surgery services provided at an outpatient hospital.

Additionally, you must pay a $40 copayment for physical and occupational therapy provided at an outpatient hospital. 

You have been asked to pay a $440 copayment ($360 + $40 x 2) for the surgery and the physical and occupational therapy evaluations provided at an outpatient hospital. The cost share liability for the therapy evaluations have been recently adjusted by the Plan to reflect these indicated copayments. 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 copayments for the total knee arthroplasty (27447), the physical therapy evaluation (97161), and the occupational therapy evaluation (97165) provided from October 20, 2020, through
October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
January 28, 2021.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization.
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 subsequent nursing facility care provided on January 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on November
26, 2020.

You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

The Plan is correct in this case. Medicare pays for ambulance services only when an emergency exists or when
other means of transport would endanger the patient's health. The Plan follows the same rules. The trip report
states the enrollee called for assistance due to a difficulty to breathe. The enrollee had known COPD.

The enrollee was found stable and speaking in complete sentences. The enrollee was in no apparent distress
and breathing normally. No life threats were found and no need for life saving intervention. Based on the
records provided, the enrollees condition did not warrant ambulance transport. The records do not show that
transport by means other than an ambulance would have endangered the enrollee's health. Medicare coverage
criteria for ambulance transport were not met. Therefore, we decided that the Plan does not have to pay for
ambulance transport provided to the enrollee on November 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on January 29, 2021.
You asked the Plan to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888). You say that Medicare should cover the transport you received when you were moved from one facility to a rehab facility in Dallas for inpatient therapy that was ordered by your provider. The Plan denied your request. The Plan says the mileage beyond the closest appropriate facility was not billed to the health Plan per CMS guidelines for ambulance transport and not included in the bundled payment.
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers ambulance transportation to the nearest appropriate facility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888) have not been met. Specifically, the record shows that you received transportation services beyond the nearest appropriate facility. This means that the additional ambulance mileage is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on
January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99202) provided on December 30, 2020.
You asked the Plan to pay for the office services. You say that this provider was on a list of recommended chiropractor's that you were given by a different health plan a few years ago and this is why you contacted the provider when you were unable to receive care from your current health plan to alleviate your pain. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 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 the office services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99202) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultations and treatment with an out-of-network provider.

You asked the Plan to pre-approve out-of-network care. You say that you would like to continue your care with the providers you have been going to. The Plan denied your request. The Plan says the documentation does not support the authorization of out-of-network care.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 provide out-of-network care. Our reviewer says that coverage criteria is not met to approve out-of-network care. The Plan has in-network specialists available. Our physician reviewer found the records provided do not support the medical necessity or reasonableness of your request for long term approval of out of network 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 out-of-network care have not been met. Specifically, the records provided do not support the medical necessity or reasonableness of the enrollee's request for long term approval of out of network services. Therefore, we decided that the Plan does not have to pre-approve consultations and treatment with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the portable electric lift purchased on July 31, 2020. 
 
You asked the Plan to reimburse you for the portable electric lift (E0630). You say that you are wheelchair 
bound and the lift makes it possible for you to get out of bed. The Plan denied your request. The Plan says that 
there is no clinical documentation to support the criteria. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the portable electric lift (E0630) by a contract provider. The file does not show that the 
Plan provided notice that the portable electric lift (E0630) would not be covered. Under Medicare rules, this 
means the portable electric lift (E0630) is considered approved by the Plan. Therefore, we decided that the Plan 
has to reimburse you for the portable electric lift purchased on July 31, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on February 19, 2021.

You asked the Plan to pay for the hearing aids. You say that the representative from the office advised you that your insurance would pay for the hearing aids. The Plan denied your request. The Plan says the dollar limit maximum for this service has been met.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only one hearing aid(s) every 3 years. 

We looked at the file and the Plan's rules. The file shows that your received coverage for hearing aids provided on April 19, 2019. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Gel.
You asked the Plan to pre-approve Diclofenac Gel. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Diclofenac Gel.
Benefits for Diclofenac Gel 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.

You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 an intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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 Intracept at L3, L4, and L5 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 an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.

You asked the Plan to pre-approve facet injections. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures is considered
medically reasonable and necessary 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 facet injections.

Our reviewer says that the services are not medically necessary. Our physician reviewer found prior injections did not provide significant pain relief. The request is deemed 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 facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the foot x-rays (CPT code 73630) provided on March 31, 2021.
You asked the Plan to waive the copayment for the foot x-rays. You say that all visits were for a post-op from your surgery rendered on December 4, 2020. You state that you were told there would be no copayment for the post-op visit. The Plan denied your request. The Plan says the foot x-ray services were not rendered within the global period of your outpatient bunion procedure rendered on December 4, 2020.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the foot x-rays (CPT code 73630) on March 31, 2021. The services performed were not within the global period of your procedure that was done on December 4, 2020. Furthermore, the services would not be covered because the Medicare rules say that a global surgical package includes certain services that are associated with the surgery performed and a global surgical package does not include diagnostic tests and procedures, including diagnostic radiological procedures. Therefore, you are asked to pay a $10 copayment for the foot x-rays. Your 2021 EOC states that enrollees must pay a $10 copayment per day for Medicare-covered X-rays. 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 foot x-rays (CPT code 73630) provided on March 31, 2021.