Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 11, 2021.
You asked the Plan to pay for an eye refraction. You say that this service should be covered since it is part of the normal exam. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services for people after cataract surgery. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. This service was performed for medical vision purposes, and therefore, is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on
September 11, 2020.
You asked the Plan to pay for hospital discharge day management. You say that the service provided was not
hospice related. The Plan denied your request. The Plan says Original Medicare would be responsible for
payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 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 the hospital discharge day management (99238) provided on
September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), the arthrocentesis, aspiration and/or
injection, of a major joint or bursa; without ultrasound guidance (20610), and the hyaluronan or derivative,
Orthovisc, for intra-articular injection, per dose (J7324) rendered by the OON provider on March 24, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the office visit (99214), the arthrocentesis, aspiration and/or injection, of a major
joint or bursa; without ultrasound guidance (20610), and the hyaluronan or derivative, Orthovisc, for intraarticular
injection, per dose (J7324) rendered by the OON provider on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the quantity limit for testing supplies for the enrollee.

You asked the Plan to pre-approve this request. You say that these supplies are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met for an exception to the Medicare guidelines for quantity limits to testing supplies. The enrollee is not insulin dependent and the medical records provided do not demonstrate a need to make an exception to the quantity limit.

The Plan must follow Medicare rules. Medicare has quantity limits for testing supplies. The enrollee is not insulin dependent. The enrollee does not meet the criteria that would allow an exception to the quantity limit. Therefore, we decided that the Plan does not have to pre-approve an exception to the quantity limit for testing supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and commode system.

You asked the Plan to pre-approve the shower chair and commode system. You say that the items are necessary
and medical in nature. The Plan denied your request. The Plan says the Plan follows Medicare rules and
Medicare does not cover rolling shower chairs and commode system because they are not considered medical
in nature, it will not treat your condition, and is primarily related to hygienic concerns.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured.

Therefore, we decided that the Plan does not have to pre-approve a shower chair and commode system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive
interface (E0466) to be provided by an OON provider.

You asked the Plan to pre-approve the ventilator. You say that you disagree with this decision and request
consideration of the following information. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.

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
home ventilator, any type, used with non-invasive interface (E0466) to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the extracranial duplex scan provided on
March 22, 2021, billed with code 93880-26.

You asked the Plan to pay for the interpretation of the extracranial duplex scan. You say that this is medically
necessary and should be paid. The Plan denied your request. The Plan says this was not billed with a valid
diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that coverage for codes 93880 is limited to a list of
specific diagnoses.

This claim was billed with diagnosis code R42, dizziness and giddiness. This is not listed as a code which
supports medical necessity. Therefore, we decided that the Plan does not have to pay for the interpretation of
the extracranial duplex scan provided on March 22, 2021, billed with code 93880-26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucynta.
You asked the Plan to pre-approve Nucynta. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Nucynta.
Benefits for Nucynta 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.

You asked the Plan to pre-approve Ondansetron. You say that this is medically necessary. The Plan denied
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug
plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ondansetron.

Benefits for Ondansetron 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 pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you cannot care for yourself. The Plan denied your request. The Plan says you do not require daily inpatient skilled nursing or therapy needs.
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 physician reviewer found that you are able to accomplish bed mobility and transfers with maximum assistance. You do not fully cooperate with therapy due to a fear of falling. You are able to stand up with moderate assistance and able to take 5-6 steps to a chair with a rolling walker and moderate assistance. You are medically stable and do not have any complex daily wound care, parental medications, or required care for a feeding tube. It is unlikely you would tolerate or cooperate with daily therapy due to pain and anxiety. Although further rehab services would be appropriate, you do not require skilled nursing and/or skilled therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from
October 5, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health care. Our
physician reviewer found based upon review the records provided for the admission of this enrollee does not
meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 18,
2021, forward as this enrollee was not shown to be a danger to themselves or others. The enrollee was not
showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was
not showing any aggressive behaviors, or any treatment required for acute threats of safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care from October 5, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve oxygen concentrator. You say that you will need to stay with your daughter and cannot transport your oxygen concentrator back and forth. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you already have an oxygen concentrator and a second concentrator would serve the same purpose.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have oxygen concentrator. A second oxygen concentrator serves the same purpose as the oxygen concentrator you already have. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 92604. We decided that the Plan does not have to pay for CPT 92584.
You asked the Plan to pay for the denied services. You say that this should be paid for. The Plan says that the coverage requirements were not met.
We decided that the Plan has to pay for CPT 92604.
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 rules say that the services are covered when they are medically necessary. 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 for CPT 92604. Our reviewer says that this service is considered medically reasonable and necessary. Our physician reviewer found that the plan's denial does not address the programming of cochlear implants. Consequently, a determination will be made based on medically reasonable and necessary criteria. Regular programming of a cochlear implant is important for optimizing the device, and the available documentation in the case file supports that it was medically reasonable and necessary for the enrollee 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 92604 have been met. Therefore, we decided that the Plan has to pay for 92604.
We also decided that the Plan does not have to pay for CPT 92584.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The case file does not support the coding of CPT 92584. Specifically, there is no situation in which this case can be paid separately from CPT 92604. Based on this information, we decided that Medicare rules for coverage of 92584 have not been met. Therefore, we decided that the Plan does not have to pay for 92584.
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: 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 does not meet criteria.
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 your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF or can fully be tolerated on an intensive IRF level. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not required. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 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 be provided at a lower level of 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and an outpatient
surgical procedure, provided from February 28, 2020, to March 26, 2020.
You asked the Plan to waive the copayments for an inpatient hospital stay and an outpatient surgical procedure.
You say that the MOOP amount for 2020 has been met and the enrollee should not owe any other charges. The
Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that the in-network
MOOP amount for 2020 is $6,700. The enrollee's contract with the Plan also clearly says the enrollee
must pay a $390 copayment for days 1-5 for inpatient hospital care. The enrollee's contract with the Plan also
clearly says that the enrollee must pay a $390 copayment for outpatient surgery, including services provided at
hospital outpatient facilities.
The enrollee had an inpatient hospital stay from February 28, 2020, to March 11, 2020. The record shows that
the enrollee had only paid $3,407.02 toward the $6,700 MOOP amount prior to receiving the services.
Therefore, the enrollee is responsible to pay a $390 copayment for days 1-5 (February 28, 2020, to March 4,
2020). $390 (copayment) x 5 (inpatient days) = $1,950.
The enrollee received an outpatient surgical procedure at an outpatient hospital facility on March 26, 2020. The
record shows that the enrollee had only paid $5,457.02 toward the $6,700 MOOP amount prior to receiving the
services. Therefore, the enrollee is responsible to pay the $390 copayment.
The total amount the enrollee owes is: $2,340.
The enrollee has been asked to pay the total copayment amount of $2,340 for an inpatient hospital stay and an
outpatient surgical procedure. An inpatient hospital stay falls within the inpatient hospital care benefit category.
An outpatient surgical procedure falls within the outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers 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 copayments for an inpatient hospital stay and an outpatient surgical procedure, provided from
February 28, 2020, to March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V Leiden genetic testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this testing is not clinically efficacious.

The Plan must follow Medicare rules. Medicare rules say that Factor V Leiden testing is not considered clinically efficacious. 

Tests that are not considered clinically efficacious cannot be covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor V Leiden genetic testing for the enrollee.