Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home health services.  You asked the Plan to pre-approve the home health services. You say that you would like reconsideration because the requested home health services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the home health services.  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 home health services. Our reviewer says that ongoing home health services are not shown to be medically necessary or reasonable. Our physician reviewer found you do not have documented, ongoing, skilled nursing needs.  There is no clear evidence as to why you, your home health aide and/or your daughter cannot provide the required wound 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza injection 18mg/3ml for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this does not fall under Part B coverage.

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 Victoza injection 18mg/3ml for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ingrezza.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 Ingrezza.

Benefits for these services 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from July 1, 2021, to July 27, 2021.  You asked the Plan to waive the copayment for the SNF services. You say that you don't remember being in the facility for this length of time. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services.   Records show that you were in the SNF for 26 days.  You were not charged a copayment for the first 20 days of the stay.  For the remaining 6 days, you were charged a $184 copayment per day, for a total of $1104. This copayment applies regardless of your satisfaction with the stay. 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 skilled nursing facility (SNF) services you received from July 1, 2021, to July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided on September 30, 2021.

You asked the Plan to pre-approve foot orthotics. You say that you have better balance and walking. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a hearing test provided on August 17, 2021.  You asked the Plan to waive the copayment for a hearing test. You say that you agree with the specialist office visit copayment but do not agree with the additional copayment for hearing services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for each specialist visit and for each diagnostic hearing exam.   You have been asked to pay a $40 copayment for a hearing test. A hearing test falls within the physician/practitioner services, including doctor's office visits 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 hearing test provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the follow-up visit you had with a doctor in Thailand on January 30, 2021.  You asked the Plan to pay for the follow-up visit. You say that you had back surgery in Thailand in January of 2020.  You stated that you returned to Thailand in January of 2021 and had a scheduled follow-up visit with the surgeon. You feel as if this follow-up visit should be covered as part of the surgery. The Plan denied your request. The Plan says the only services it covers outside of the country are emergency services.  That is why the Plan retracted payment for this visit.  The Plan must follow Medicare rules. Medicare rules say that services outside of the United States are not covered.  The Plan will cover emergency care outside of the country.  However, a scheduled follow-up visit is not an emergency service.  There is no coverage under your Plan or under Medicare for non-emergency care rendered outside of the country, regardless of the appropriateness of the care. Therefore, we decided that the Plan does not have to pay for the follow-up visit you had with a doctor in Thailand on January 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laboratory work to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the laboratory work. You say that you have never had an issue with blood drawn at the out-of-network laboratory facility. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the laboratory work to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placements of intra-socket biological dressings (D7922).

You asked the Plan to pre-approve the placements of intra-socket biological dressings. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve placements of intra-socket biological dressings (D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a caries risk assessment and documentation (D0603).  You asked the Plan to pre-approve the caries risk assessment and documentation. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve a caries risk assessment and documentation (D0603).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an endodontist.

You asked the Plan to pre-approve dental care from an endodontist. You say that these services are medically necessary. The Plan denied your request. The Plan says in order to be eligible for coverage, supplemental dental care must be received from a participating general dentist. Services from a dental specialist, such as an endodontist, are not covered. In addition, problem-focused exams are not covered by your dental benefit, and endodontic services are not covered by your plan for those over the age of 21.

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. Supplemental dental services must be performed by a participating general dentist. 

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. In addition, the request is for services to be provided by an endodontist, which is not a general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation with an endodontist.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from July 7, 2021, through
July 26, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says Original Medicare will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for SNF services provided from July 7, 2021, through
July 26, 2021.
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 this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a primary care physician (PCP) visit provided on September 1, 2021.  You asked the Plan to waive the deductible for the PCP visit. You say that since you have Medicaid, you should not have to pay anything. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  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 $203 deductible which applies to certain items and services.   The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $203 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the PCP visit was received on September 1, 2021. Please note that the Plan has indicated that the deductible amount has been billed the Medicaid. Therefore, we decided that the Plan does not have to waive the deductible for a primary care physician (PCP) visit provided on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerendia tablets.

You asked the Plan to pre-approve the Kerendia tablets. You say that the enrollee has type 2 diabetes mellitus with diabetic chronic kidney disease. You also say that Kerendia is the right medication for this enrollee and is medically necessary. The Plan denied your request. The Plan says Kerendia tablets are not covered under the enrollee's plan under any normal circumstances.

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 Kerendia tablets.

Benefits for the Kerendia tablets 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: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the angiography services (75726-26-59) provided on April 7, 2021.  You asked the Plan to pay for code 75726-26-59. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have been met. Therefore, we decided that the Plan has to pay for the angiography services (75726-26-59) provided on April 7, 2021.   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 pre-approve four gingival irrigations (D4921 x4).  You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve four gingival irrigations (D4921 x4).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive rehabilitation program. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation using a stretcher.

You asked the Plan to pre-approve routine transportation using a stretcher. You say that the enrollee is bed
bound and needs to get to medical appointments. The Plan denied your request. The Plan says the service at
issue is not a covered benefit.

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.

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. Therefore, we decided that the
Plan does not have to pre-approve routine transportation using a stretcher.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation mileage.  You asked the Plan to provide coverage for additional routine transportation mileage. You say that the only dental office that accepts both insurance coverage is 89 miles away from your home and 14 miles over the 75-mile benefit limit. You say you would like the Plan to cover the extra 14 miles over the transportation limit so you can attend your dental appointment. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee's request will exceed benefits limit set in the agreement for additional mileage. Your benefit only allows 75 miles of driving distance trips for this service. You will have exceeded your benefit limit.  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.   We looked at your request, the records in the case file, and the rules. The file shows that the routine transportation benefit must not exceed 75 miles of driving distance for each one-way trip. The distance to your dentist office will exceed the benefit mileage limit. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation mileage.