Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Favorable

 We decided that the Plan has to pay for subsequent hospital care provided on December 22, 2018.  You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says that the member was in Hospice on this date of service.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided us with proof of Hospice enrollment. Therefore, we decided that the Plan has to pay for subsequent hospital care provided on December 22, 2018.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and topical application of fluoride varnish (D1206) provided August 18, 2021.
You asked the Plan to pay for the periodic oral exam and fluoride varnish. You say that you don't understand why the services are not covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for oral exams and the fluoride varnish is not a covered service.
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 covers the periodic oral exam and fluoride varnish when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The Plan provided documentation showing that oral exams were previously covered on May 13, 2021, and July 12, 2021. Based on this information, we decided that the Plan's
frequency limit for coverage of the periodic oral exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the fluoride varnish is not among those covered services. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and topical application of fluoride varnish (D1206) provided August 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition therapy.  You asked the Plan to pre-approve the requested services. You say that the enrollee requires enhanced supportive nutritional therapy. The Plan denied your request. The Plan says the enrollee is not a good candidate for tube feeding.  The Plan must follow Medicare rules. The rules say that parenteral nutrition is only covered under certain medical indications.    We looked at the file and the rules. The records do not show that the enrollee has a disorder that impairs the ability of nutrients to be transported through the gastrointestinal system. 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 intradialytic parenteral nutrition therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve EpiFix wound care services.  You asked the Plan to pre-approve the requested services. You say that EpiFix will decrease the risk of infection by promoting wound healing. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in the peer-reviewed literature.  The Plan follows Medicare rules. Medicare rules say that skin graft substitutes are only covered under certain medical indications.   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 the enrollee has a non-healing right ischial wound related to chronic osteomyelitis. The wound has filled in nicely in the center of the wound bed however in the periphery there is still depth probing to the deep-seated tissue near the bone in the 360-degree plane. The enrollee is responding very well to negative pressure wound therapy. The requested service is not indicated for the enrollee's condition. Therefore, the requested treatment is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve EpiFix wound care services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for a diagnostic colonoscopy provided on October 13, 2021.  You asked the Plan to waive the copayments for a diagnostic colonoscopy. You say that the colonoscopy should be covered at 100% with no copayment. The Plan denied your request. The Plan says the proper copayment was applied because polyp or other tissue was found and removed during the service.  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 $150 copayment for Medicare-covered services provided in an ambulatory surgical center.   You have been asked to pay a $150 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 copayments for a diagnostic colonoscopy provided on October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient procedure provided on November 24, 2021, through November 29, 2021.  You asked the Plan to waive the copayment for an outpatient procedure. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share was applied 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 $345 outpatient hospital copay for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.    You have been asked to pay a $345 outpatient hospital copay for an outpatient procedure. This service 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 an outpatient procedure provided on November 24, 2021, through November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical removal of an erupted tooth (D7210), provided on July 7, 2021.  You asked the Plan to pay for the surgical removal of an erupted tooth. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered benefit nor was it obtained through a contracted 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical removal of an erupted tooth (D7210), provided on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for diagnostic tests and outpatient services provided on April 2, 2021, and May 3, 2021.  You asked the Plan to waive the copayments for the diagnostic tests and outpatient services. You say that the billing was done incorrectly, and you were told the services were covered. The Plan denied your request. The Plan says the services were covered, and the proper copayments were applied for the services.   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 $25 copayment for Medicare-covered non-radiological diagnostic services, a $110 copayment for Medicare-covered radiological diagnostic services, and a $260 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center. The total amount of copayments for the services was $395 ($25 copayment + $110 copayment + $260 copayment).  You have been asked to pay a $395 copayment for the diagnostic tests and outpatient services. The diagnostic tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The outpatient services fall within Outpatient Surgery and Other Medical 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 copayments for diagnostic tests and outpatient services provided on April 2, 2021, and May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 27, 2021.  You asked the Plan to waive the copayment for the colonoscopy. You say that the services should be covered as you have never had to pay this much before. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for Outpatient Hospital Observation.     You have been asked to pay a $450 copayment for a colonoscopy. Colonoscopies fall within the Outpatient Hospital Observation 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 colonoscopy provided on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on October 15, 2021.  You asked the Plan to waive the copayment for the outpatient surgery services. You say that you have this procedure every two years and this service should fall under preventative measures. The Plan denied your request. The Plan says the proper copayment was 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). Your contract with the Plan clearly says that you must pay a $200 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.   You have been asked to pay a $200 copayment for the outpatient surgery services. The outpatient surgery services 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 outpatient surgery services provided on October 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide additional routine transportation trips.  You asked the Plan to provide additional transportation. You say that this transportation is vital for you to be able to get to your dialysis appointments. The Plan denied your request. The Plan says the routine transportation benefit covers a maximum of 20 trips per year. You have used all 20 of your available trips. Additional trips are not a covered benefit and cannot be approved.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lyrica.  You asked the Plan to pre-approve Lyrica. You say that the enrollee needs the name brand. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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 Lyrica.     Benefits for Lyrica 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received on September 24, 2021.  You asked the Plan to waive the copayment for the lab services. You say that you had these labs in September instead of during your annual physical due to the pandemic. You stated that this copayment should be waived because it was related to your physical. The Plan denied your request. The Plan says you were charged this copayment 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 lab services.   You have been asked to pay a $10 copayment for the lab services. Your contract explicitly states that your annual physical includes the following services: bodily systems examinations, measurement and recording of vital signs, a complete prescription medication review, and a review of recent hospitalizations. It does not include lab services or other testing.  Separate cost sharing can apply for these additional services. 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 lab services you received on September 24, 2021.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pre-approve 4 additional services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. (G0151).  You asked the Plan to pre-approve the home health physical therapy visits. You say that you will continue to service the enrollee throughout the appeal process. You are appealing for 6 physical therapy visits which was denied. The Plan denied your request. The Plan says that medical necessity has not been established for home health physical therapy services from 02/07/2022 through 03/25/2022. However, 2 additional visits have been approved.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the home health physical therapy visits. Our reviewer says that the medical necessary for continued home health physical therapy coverage was partially met. Our physician reviewer found the requested home health physical therapy services should be covered through 2/16/2022. The enrollee made steady progress in home health physical therapy through 2/16/2022. Receiving therapy outside of the home would, as a practical matter, have been difficult due to the enrollee's age, deafness and foot drop. By the end of 2/16/2022, the enrollee was modified independent with all mobilities, appearing able to receive care at a lower level of function (i.e. home exercise program or outpatient therapy). Four of the six requested visits should be approved, thereby providing coverage for 2/7/2022, 2/9/2022, 2/14/2022 and 2/16/2022. The two remaining requested visits are not medically necessary or reasonable.  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 home health physical therapy visits have not been met. Therefore, we decided that the Plan has to pre-approve 4 additional services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. (G0151).       If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation services.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are no medial branch blocks at the requested levels.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.  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 the enrollee has chronic low back pain. Previous imaging studies of the lumbar spine reveals degenerative disc disease. There is no documentation of two medial branch blocks at the requested levels. The enrollee has also not received prior ablation services at the requested levels. The clinical information provided does not support the requested procedure. The review has determined that the requested RFA is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.