Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty additional skilled nursing visits and seventeen
additional home health aide visits after February 17, 2021.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says there is no need for additional skilled nursing visits and home health aide visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer
found the records do not show that skilled nursing (SN) services are required to effectively provide treatment,
care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance
program to maintain the enrollee's condition and/or prevent deterioration. The enrollee does not have any
complex wound care, intravenous (IV) antibiotics, new enteral feedings or other SN needs. The enrollee's
medical conditions are stable. The enrollee has been educated in disease management. The enrollee does not
need SN to remind them to take their insulin properly. The enrollee's needs do not require ongoing SN care.
The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or
services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to
maintain the enrollee's level of function and/or prevent deterioration. As the enrollee does not require skilled
therapy or SN services the request for home health care services is not appropriate and not medically necessary
for the treatment of the enrollee's illness or injury by the skilled professional staff.

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 twenty additional skilled nursing visits and seventeen additional home health aide visits
after February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.

You asked the Plan to pre-approve Dupixent. You say that the enrollee has been on the requested drug for over a year and has had major improvement. You say that this is the only medication that has helped the enrollee. The Plan denied your request. The Plan says the drug in dispute is not covered under the enrollee's contract.

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 Dupixent.

Benefits for Dupixent 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for one-month supply allowance for therapeutic continuous
glucose monitor (K0553) provided on October 25, 2019, by an out-of-network (OON) provider.

You asked the Plan to pay for 1-month supply allowance for therapeutic continuous glucose monitor. You say
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan
says there was no prior authorization received for services rendered by an OON provider.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for one-month supply allowance for therapeutic continuous glucose monitor (K0553) provided on
October 25, 2019, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Hepatitis C antibody screening received on October 5, 2020.

You asked the Plan to pay for the screening. You say that this should be paid for. The Plan denied your request. The Plan says the benefit limit has been exceeded.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The plan rules state that Hep S screenings are covered once per year. 

The file shows that these services were received twice in one year. Based on this information, we decided that Medicare rules for coverage of the screening have not been met. Therefore, we decided that the Plan does not have to pay for a Hepatitis C antibody screening received on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device.

You asked the Plan to pay for the intermittent limb compression device. You say that the service provided was medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare because there is no evidence of ulcers or lower extremity edema.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99222) provided on August 31, 2019.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because you did not receive proper notice of the member's benefit determination. The Plan denied your request. The Plan says this claim was received past the 12-month allowable time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the initial hospital care was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided on August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge services provided on May 8, 2020.

You asked the Plan to pay for the physician service. You say that the medically necessary services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says that it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 nursing facility discharge services provided on May 8, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a duplex scan (93978).

You asked the Plan to pre-approve a duplex scan. You say that this is medically necessary. The Plan denied
your request. The Plan says that a similar study was previously performed, and no information was provided to
show this was not sufficient.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary. The rules also say that uses
for ultrasound diagnostic procedures not listed in Category I or II are left to local MAC discretion. In view of
the rapid changes in the field of ultrasound diagnosis, uses for ultrasound diagnostic procedures other than
those listed under Categories I and II should be carefully reviewed before payment. Medical justification may
be required.

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 a duplex scan. Our reviewer says that
the requested duplex scan considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee is status post bilateral common iliac artery angioplasty and stenting. The enrollee has
evidence of recurrence based on elevated velocities within the common iliac artery stents bilaterally and
slightly diminished ankle brachial indexes. While the patient did not require intervention at the last visit, a
follow-up within 6 months with repeat aortic duplex scanning is appropriate and medically necessary as, if the
patient develops significant worsening of her restenosis, an intervention might be indicated.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a duplex scan have been met. Therefore, we decided that the Plan has to preapprove
a duplex scan (93978).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 7, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clonazepam tablet, 0.5 mg.

You asked the Plan to pre-approve the self-administered drugs. You say that Clonazepam is the only medication that the enrollee receives therapeutic relief when he has an anxiety attack. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 Clonazepam tablet, 0.5 mg.

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is 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 these services when provided during a routine eye exam.

We looked at the file and the Plan's rules. The requested eye refraction was not provided during a routine eye
exam. Eye refractions are only covered when provided during a routine eye exam. Based on this information,
we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the
Plan does not have to pay for the eye refraction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three osseous surgeries (D4261 x3).

You asked the Plan to pay for the osseous surgeries. You say that the dentist office told you that you would only be responsible for an $850 payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three osseous surgeries (D4261 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services provided on August 28, 2020 by an out of network provider.

You asked the Plan to pay for the initial hospital care services. You say that the doctor should not be penalized because the hospital staff did not obtain authorization. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the initial hospital care services provided on August 28, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vumerity.

You asked the Plan to pre-approve Vumerity. You say that the requested drug is medically necessary due to the severity of the enrollee's disease. The Plan denied your request. The Plan says the drug in dispute is intended for patient self-administration and the enrollee does not have Part D coverage through this plan.

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 Vumerity.

Benefits for Vumerity 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 23, 2020.

You asked the Plan to pay for the physician service. You say that the services rendered to the enrollee were medically necessary. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says that it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 subsequent nursing facility care provided on March 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup services (D2950) provided to you on October 4, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 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 services are not among those covered under this benefit. The Plan covers only those dental services for which the codes are listed in the Evidence of Coverage. Dental code D2950 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the core buildup services (D2950) provided to you on October 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3320), crown repair (D2980), cone
beam CT capture and interpretation (D0364), and preventive procedure (D1999) provided on September 11,
2020.

You asked the Plan to pay for the endodontic therapy, crown repair, cone beam CT capture and interpretation,
and preventive procedure. You say that you do not understand why these services are not covered. The Plan
denied your request. The Plan says these services are not covered benefits under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
endodontic therapy (D3320), crown repair (D2980), cone beam CT capture and interpretation (D0364), and
preventive procedure (D1999) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1999, D0603) you received on September 3, 2020.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The Plan covers only those dental services for which the codes are listed in the Evidence of Coverage. Dental codes D1999 and D0603 are not listed, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for the dental services (D1999, D0603) you received on September 3, 2020.