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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says care can be received in another setting.
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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. The enrollee is ambulating household distances and tending to ADLs with
minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of the enrollee's condition. The enrollee's care needs can, as a practical matter, be provided at a
lower level of care (ex. home, AL, LTC).
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation mileage (A0120).     You asked the Plan to provide coverage for additional routine transportation mileage. You say that you need to see this provider as he is the only one who can do the tests and procedures that you need for your medical condition. The Plan denied your request. The Plan says you requested additional mileage with a total of 87 miles, which is 37-miles of overage for routine transportation trips. The Plan also says that this trip exceeds the benefit mileage limit of 50 miles one-way.  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 36 one-way routine transportation trips, and each one-way trip must not exceed 50 miles of driving distance.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation mileage (A0120).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 10, 2020.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says your Plan covers ambulance transportation only when you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not covered under your Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on October 10, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional services. You say that the enrollee continues to feel unsteady on her feet during functional tasks. The Plan denied your request. The Plan says the enrollee appears to be at her highest level of function realistically attainable.
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 additional services. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. She has had extensive therapy, but the records do not indicate her deficits require the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. She has had extensive therapy, and should be able to transition to a home exercise program. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design, or deliver a program to maintain the enrollee's current condition, or to prevent 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amifostine for the enrollee.
You asked the Plan to pre-approve Amifostine. You say that this is medically necessary. The Plan denied your request. The Plan says Amifostine is not proven to be effective for preventing mucositis associated with radiation treatment for prostate cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Amifostine. Our reviewer says that Amifostine is not medically reasonable and necessary for the enrollee in this case. Amifostine is not FDA-approved for the enrollee's diagnosis of prostate cancer. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Amifostine. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Amifostine have not been met. Therefore, we decided that the Plan does not have to pre-approve Amifostine for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's maximum function could be jeopardized by any delay. You say that the enrollee should be admitted to regain function, ambulate safely, perform activities of daily living and return home with quality of life improvement. The Plan denied your request. The Plan says the criteria for coverage 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 enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a participating provider on January 16, 2019 to October 8, 2019.
You asked the Plan to waive the coinsurance for chemotherapy. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B drugs/chemotherapy. The enrollee has been asked to pay a 20% coinsurance of the allowed amount for chemotherapy. The total amount you are being asked to pay is $2,012.59. Chemotherapy falls within the Medicare Part B drugs/chemotherapy benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a participating provider on January 16, 2019 to October 8, 2019.
Please note that this decision is only regarding the following dates of services: January 16, 2019, February 18, 2019, April 15, 2019, May 20, 2019, May 28, 2019, June 11, 2019, July 16, 2019, August 13, 2019, and September 10, 2019.
Please contact the Plan regarding appeals for any other dates of service.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on January 13, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for ambulance services. The enrollee has been asked to pay a $250 copayment for an ambulance trip. The correct copayment has been applied to the services that were provided. An ambulance trip falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on January 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient therapy services provided from July 1, 2019 to August 14, 2019.
You asked the Plan to waive the copayment for outpatient therapy services. You say that you were not aware that the services were being performed. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for per provider, per date of service for outpatient rehabilitation services under the Select Rx plan. The enrollee has been asked to pay $640 for 32 sessions of outpatient therapy services at $20 a session ($20 copayment x 32 sessions = $640). Outpatient therapy services fall within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient therapy services provided from July 1, 2019 to August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) and to pay more for the first intraoral periapical x-ray (D0220) and crown (D2740) provided on July 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the local anesthesia or pay more for the first intraoral periapical x-ray and crown. You say that you were under the impression that the service would be covered at least 25% according to your summary of benefits. The Plan denied your request. The Plan says local anesthesia is not a covered expense under your dental plan. The Plan says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.  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, local anesthesia in conjunction with operative or surgical procedures (D9215) is not among those covered under this benefit. The contract also clearly states that you are responsible for a 50% coinsurance for intraoral x-rays, and a 75% coinsurance for crowns, plus the difference between the billed amounts and allowed amounts when the services are received OON. Therefore, we decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) and to pay more for the first intraoral periapical x-ray (D0220) and crown (D2740) provided on July 12, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional intraoral x-rays and panoramic x-ray provided on June 30, 2021.  You asked the Plan to pay for the additional intraoral x-rays and panoramic x-ray. You say that $800 was billed, and all services should have been covered. The Plan denied your request. The Plan says reimbursement has already been issued for one intraoral complete series x-ray.  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, you also have a maximum benefit of one intraoral x-ray every year and one complete series or panoramic x-ray every five years. The Plan paid for one intraoral complete series x-ray provided on June 30, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-rays and panoramic x-ray provided on June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve needs are custodial in nature.
You asked the Plan to pre-approve this is medically necessary, as the enrollee needs more PT and OT.. You say that this is medically necessary, as the enrollee needs more PT and OT. The Plan denied your request. The Plan says needs are custodial in nature.
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 this is medically necessary, as the enrollee needs more PT and OT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this is medically necessary, as the enrollee needs more PT and OT. have not been met. Therefore, we decided that the Plan does not have to pre-approve needs are custodial in nature.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0452) provided on July 23, 2021.  You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says screening testing is not a Medicare benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the drug testing services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any medical records. Without this information we are unable to determine why this testing was ordered or how it will affect treatment for the member. There is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0452) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the primary care office visits you had on June 28, 2021, and July 16, 2021, and the specialist visit you had on July 1, 2021.  You asked the Plan to waive the copayments for the primary care and specialist visits. You say that you were told there would be no copayments for these visits since they were follow-ups from your inpatient stay. The Plan says that the only time that follow-up visits don't have a copayment is if you have surgery and then only for the surgeon who performed the surgery. The Plan denied your request. The Plan says none of these claims were billed as follow-up visits, so these copayments were charged correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for visits with non-preferred primary care providers and a $50 copayment for visits with a specialist.   You have been asked to pay a $10 copayment for the primary care visits and a $50 copayment for the specialist visit. Neither of the primary care providers you saw are preferred primary care providers. This means that you have been asked to pay the correct amounts 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 primary care office visits you had on June 28, 2021, and July 16, 2021, and the specialist visit you had on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 5, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient observation provided from June 17, 2021, to June 18, 2021.  You asked the Plan to waive the copayment for the outpatient observation. You say that you should not have to pay this much because you were not billed properly. The Plan denied your request. The Plan says you have been asked to pay 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 $395 copayment for each outpatient hospital observation visit.    You have been asked to pay a $395 copayment for the outpatient observation. The outpatient observation falls within the "Outpatient Hospital Observation" benefit category. The medical record shows you were admitted to observation. 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 outpatient observation provided from June 17, 2021, to June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested services. You say that the enrollee has failed more than six months of conservative treatment. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that interspinous stabilization devices are experimental. More research is needed to show safety and efficacy of the devices.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.