Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the surgery provided on July 30, 2019.
You asked the Plan to waive the coinsurance for the surgery. You say that you should not be responsible for the coinsurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% of the cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or facility charges, observation room/stay charges, physician charges and surgical charges. You have been asked to pay $840.45 which is 20% of the allowed amount for the surgery. The allowed amount is $4,202.24. ($4,202.24 x 20% = $808.45). The surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the surgery provided on July 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on October 14, 2019 by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider. The Plan also says that there is no documentation of 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 providersonly 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 has network providers available who can provide 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 forthe subsequent nursing facility care provided on October 14, 2019 by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services. You asked the Plan to pre-approve the physician's services. You say that you have seen many providers who have not been able to help you and you would like to see this provider for Botox for mouth pain. The Plan denied your request. The Plan says you 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 from the plan. 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.You asked the Plan to pre-approve medical nutrition therapy services. You say that you feel these services are necessary and nutrition therapy would help you reach your goals.The Plan denied your request. The Plan says the denial for authorization for these services is correct, because medical nutrition therapy is not covered by Medicare or the Plan in these circumstances.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care attendant services.
You asked the Plan to pre-approve personal care attendant services. You say that the enrollee needs help with dressing in her winter garments as well as going to and from physical therapy visits. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the services of a personal care attendant are custodial in nature and are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that custodial care, such as the services of a personal care attendant, are not covered by Medicare. We looked at the file and Medicare rules. The requested personal care attendant services are custodial in nature; therefore, they are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve personal care attendant services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the needed physical therapy and occupational therapy can be provided at a lower level of care, such as at a skilled nursing level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 your medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. You are currently in the subacute setting and does not require an acute hospital level of care. You do not require an intensive rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided at an SNF level. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve a referral to Foundation Physical Therapy Co, an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says this is a network lock-in -medically necessary care is available in-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 a referral to Foundation Physical Therapy Co, an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from September 24, 2019 to September 25, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these are not Part B covered drugs.
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 pay for the self-administered drugs provided from September 24, 2019 to September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopaedic consultation.
You asked the Plan to pre-approve orthopaedic consultation. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee must have an evaluation with a approved clinic prior to referral to an orthopaedic specialist.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The Plan contract says that enrollees with back and neck pain, with the exception of those requiring urgent surgical evaluation, must have an evaluation with a Spine Center of Excellence approved clinic prior to referral to an orthopaedic specialist or neurosurgeon. 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 orthopaedic consultation. Our reviewer says that the enrollee does not meet the criteria for the requested orthopaedic consultation at this time. Our physician reviewer found there is no compelling rational presented to support an exception to the Plan's referral requirements. Based on the available information, the Plan's denial is medically justified on the basis that it is
offering adequate care to meet the enrollee's medical needs through referral to a clinic. There is nothing unique about the enrollee's condition that would make it medically necessary for him to see the requested orthopaedic specialist at this time. The Plan has shown that its treatment plan of evaluation at a clinic prior to orthopaedic consultation meets the standard of care for treatment of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of orthopaedic consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve an orthopaedic consultation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCinacalcet HCP 30mg tablet.You asked the Planto pre-approvethe drug. You say that this is medically necesasry.The Plandenied your request. The Plansaysthis is a drug that is taken orally.The Plan must follow Medicare rules. The rules say that MedicarePart 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 Plandoes not haveto pre-approveCinacalcet HCP 30mg tablet.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the documentation provided supports the need for SNF care. You say that the enrollee requires extensive wound care, drain care, and ostomy care. You say that the enrollee is unable to sit up and would benefit from continued physical and occupational therapy. The Plan denied your request. The Plan says the enrollee has a high level of functioning and her needs can be met at a lower level of care. The Plan says that custodial care services are not covered.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The documentation indicates the enrollee's current needs including wound care can be provided by home health services. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" only in a SNF. As a practical matter this enrollee does 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services 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 the enrollee's inpatient stay is about to reach the 100 day benefit limit for this admission.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from November 21, 2019 to March 7, 2020. The Plan has covered 100 days of SNF care. Although the enrolleemay still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 29, 2019 through August 5, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found observation care would have sufficed in this clinical setting, and there was no indication from the records that this patient was expected to required acute care for more than two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acuteinpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 29, 2019 through August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression support stockings (HCPCS A6530). You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary.The Plan denied your request. The Plan says neither Medicare, nor the Medicare Advantage health plan covers this item.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression support stockings (HCPCS A6530).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on October
18, 2019.
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you have never had to pay
for these items in the past. The Plan denied your request. The Plan says that the cost share was assessed
correctly per your benefits.
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 (DME) and Related Supplies.
You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies falls within the
Durable Medical Equipment (DME) and Related 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 coinsurance for the CPAP supplies provided on October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (SEWHO) (L3960)
provided November 14, 2019.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of
the service in dispute. The Plan denied your request. The Plan says the enrollee received this same item from a
different provider on November 13, 2017. The records submitted did not include documentation to support that
the replacement of this brace was necessary due to loss or irreparable damage.
The Plan must follow Medicare rules. Medicare rules say that during the reasonable useful lifetime, Medicare
does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment
owned by the beneficiary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for
shoulder elbow wrist hand orthosis (SEWHO) (L3960) provided November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings
provided by an OON provider on August 15, 2019.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that the
enrollee confirmed with the Plan that they could use in-network or out-of-network providers with their plan and
was told this same response multiple times. You also say that the enrollee's plan changed without the enrollee
having been notified of the change. The Plan denied your request. The Plan says these services were rendered
by an OON provider. The Plan also says that services are not covered under the enrollee's contract when they
are received from an OON provider.
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 out-of-network. Therefore, we decided that the Plan does not have to pay for
the periodic oral evaluation, prophylaxis, and bitewings provided by an OON provider on August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that the records provided support the need for an inpatient mental health admission. The Plan denied your request. The Plan says the records do not show that the enrollee has continued to have problems that require inpatient mental health problems, as of March 24, 2020.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient mental health services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found it is not expected this enrollee would improve in a reasonable period of time for the dates in question as she does not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations but was reported to be back at baseline with no complaints. The enrollee was compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self or others and was compliant with her treatment. 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 inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.