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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 based on the medical records provided there is 
no documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network (OON) provider.
You asked the Plan to pre-approve hearing aids. You say that the enrollee recently had a hearing test, and he is required to have a high-end hearing aid. You also say the Plan's hearing aid provider only offers low end hearing aids for the amount of his coverage. The Plan denied your request. The Plan says hearing aids must be purchased from an in-network hearing aid provider.
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 contract says that the Plan pays up to $1,000 per ear, per calendar year for hearing aids. The Plan contract also says that the enrollee must receive services from any network hearing aid provider. We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids from an out-of-network (OON) provider.
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 in the Medicare rules section.
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 documentation does not support that there is a reasonable expectation that you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF at this time. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on September 30, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal.  We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the 
Plan does not have to pre-approve a colonoscopy to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral exam (D0120) provided on October 13, 2021.
You asked the Plan to pay for the cleaning and exam. You say that you need three cleanings per year. The Plan denied your request. The Plan says you had previous cleanings and oral exams in February and June of 2021, which were covered by the Plan. These services are only covered twice per year.
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. The Plan can cover two routine periodic oral exams completed during a dental checkup (D0120) per plan year. The Plan can cover two standard adult dental cleanings (D1110) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, these services are requested in a frequency that is not covered under this benefit. Documentation shows you have had two prior cleanings and two periodic oral exams in 2021, which were covered by the Plan. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral exam (D0120) provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (64910) provided September 3, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 64910 is not supported in the medical record. Specifically, a Qualifying Device code is 
required for the billed service. The device code billed is not a valid qualifying code for this service. Based on 
this information, we decided that Medicare rules for coverage of the surgical services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical services (64910) provided September 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200, V2762, V2784) purchased on 
October 22, 2021. 
 You asked the Plan to pay for the eyeglasses. You say that you do not understand why one of these claims 
denied and one was paid. The Plan denied your request. The Plan says on this date you purchased a pair of 
lenses with upgrades for a current pair of eyeglasses as well as a new, full set of eyeglasses with lenses and 
upgrades. You are covered for one set of eyewear per year. One of these was covered, and the other was denied 
for exceeding the frequency limitation of your 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 one unit of eyewear up to $400 per year. 
 
We looked at the file and the Plan's rules. You purchased two eyewear units on this date, and one was covered 
by the Plan. The second exceeds the Plans limit of one per year. Based on this information, we decided that the 
Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyeglasses (V2020, V2200, V2762, V2784) purchased on October 22, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nepro.
You asked the Plan to pre-approve Nepro. You say that the item is medically necessary. The Plan denied your request. The Plan says the member does not meet the criteria for this supplement.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Nepro.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod insulin delivery system. 
 
You asked the Plan to pre-approve an Omnipod insulin delivery system. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says this is not covered by Medicare Part B. 
Part D coverage may be available for this. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, such as the 
Omnipod, are not covered by Medicare Part B as they do not meet the definition of durable medical equipment. 
 
Although this may be appropriate for the enrollee, neither Medicare nor the Plan covers this device. Therefore, 
we decided that the Plan does not have to pre-approve an Omnipod insulin delivery system.  
 
Benefits for an Omnipod insulin delivery system 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 pay for surgical services provided to the enrollee on August 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not be separately billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 14301 
is a column II code to column I code 19318. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for surgical services provided to the enrollee on August 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bupropion HCL for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Bupropion HCL for the 
enrollee.  
 Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for immunization services provided on November 29, 2021.
You asked the Plan to pay for immunizations under Medicare Part B. You say that this claim should be paid. The Plan denied your request. The Plan says while a portion of this claim was paid, the immunization provided (mumps, measles, rubella) is not covered under Medicare Part B. Payment for this code should be submitted to the enrollees Medicare Part D carrier.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunizations under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to immunizations under Medicare Part B. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on September 30, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on April 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment for this service is always bundled into payment for other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 is not supported in the case file. Specifically, this code has a status indicator of B 
according to the Medicare Physician's Fee Schedule. This means that payment for this service is bundled into 
payment for other codes, and this code cannot be billed separately.  
 
 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 pay for anesthesia services provided to the enrollee on 
April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qvar Redihaler 80mcg.
You asked the Plan to pre-approve the Qvar Redihaler. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
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 Qvar Redihaler 80mcg.
Benefits for the Qvar Redihaler 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower 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 in the Medicare rules section. 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.
You are medically stable and do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Your rehab needs can be met safely at a lower intensity and alternate setting. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a behavioral health visit (90832) provided
on October 5, 2021.
You asked the Plan to waive the deductible for the behavioral health visit (90832). You say that the services
should be covered because there is not another psychiatrist within a 30-mile radius of their home and that the
visit was medically necessary. The Plan denied your request. The Plan says the deductible applied correctly
based on the services provided and there is a list of of providers that can provide these services within 30 miles.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to Outpatient mental health care.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient
mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$750 deductible which applies to Outpatient mental health care. This cost sharing is a contractual obligation
that had not been met at the time the behavioral health visit (90832) was received on October 5, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for a behavioral health visit (90832)
provided on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lithotripsy (kidney stone fragmentation) 
procedure performed on November 5, 2020. 
 
You asked the Plan to waive the copayment for the lithotripsy. You say that you were informed that you would 
not have a copayment. 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 a $100 
copayment for surgery services received at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the lithotripsy. The lithotripsy 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 copayment for a lithotripsy (kidney stone fragmentation) 
procedure performed on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 2.5mg tablets.
You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
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 Eliquis 2.5mg tablets.
Benefits for Eliquis 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 pre-approve an intermittent limb compression device (E0676).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a preventive service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).