Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is making progress in
breathing. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the
current acute setting.

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 physician
reviewer found that in this case, the enrollee was admitted to the acute care hospital with a myocardial
infarction. She underwent endovascular revascularization. The record indicates that she is making progress
being weaned for the ventilator. She continues to receive acute care services, and these have not been denied.
The medical record does not indicate that the enrollee requires services that she is not currently receiving but
that would be available at the LTACH facility.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left thoracic radiofrequency ablation (RFA).

You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (64633) and Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) (64634). You say that previous RFA's have given the enrollee significant quality of life after each one. The Plan denied your request. The Plan says the enrollee has undergone three of these procedures within the past year, so it is too soon to have the same procedure.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The record shows the enrollee has had three thoracic RFA sessions three times since January 11, 2021, exceeding the limit. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (64633) and Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) (64634) have not been met. Therefore, we decided that the Plan does not have to pre-approve left thoracic radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on May 20, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says the member's only vision benefit for eyeglasses is only payable after cataract surgery; therefore, this is a non-covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear. The services you asked the Plan to pay for are considered routine eyewear. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on May 20, 2021.
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. The Plan denied your request. The Plan says you do not
require skilled nursing or therapy services on a daily basis in an inpatient setting.
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 from a nursing perspective, you had stable vital signs, your lungs were clear, and you were treated
for arthritic pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you
were at a supervision to contact guard assist level with functional mobility. You required varying assist with
activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient
basis in a 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services provided to the enrollee on February 18, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the enrollee does not have a covered indication for this testing.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 to pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee was evaluated for medical conditions including Chest pain, unspecified; Essential (primary) hypertension;Crohn's disease of small intestine without complications; Gastro-esophageal reflux disease without esophagitis; Nicotinedependence, cigarettes, uncomplicated; Other long term (current) drug therapy; Family history of diabetes mellitus. The review indicates that the enrollee had a covered indication for this testing. 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 services have been met.
Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on February 18, 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 pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided December 28, 2020.

You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you were not aware there was a frequency limit for the services. The Plan denied your request. The Plan says the enrollee has exceeded the frequency limit for these services, and therefore they are not covered.

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 comprehensive oral exam and complete series of x-rays once every three plan years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam and complete series of x-rays was previously covered on June 20, 2018. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam and complete series of x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided December 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide (G0156) for companionship
services.

You asked the Plan to pre-approve the home health aide. You say that the enrollee lives alone. You say that
they will benefit with obtaining companionship services daily. You say that the enrollee struggles with the
management of taking their medications daily. You also say that if someone is with them, they can assist with
the use of taking the medications correct. The Plan denied your request. The Plan says companionship is not
one of the services covered because it is considered personal care that does not require skilled nursing or
medical services.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health aide have not been met. Specifically, we find that the services at issue in this case
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home
health aide (G0156) for companionship services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tracheostomy supplies provided on April 23, 2021 by an out-of-network provider.

You asked the Plan to pay for tracheostomy, inner cannula (A4623) and tracheostomy tube collar/holder, each (A7526). You say that the supplies were medically necessary. The Plan denied your request. The Plan says you did not request prior authorization as required.

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for tracheostomy supplies provided on April 23, 2021 by an out-of-network provider.
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 May 23, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you collapsed in
public, and you were sweating and experiencing hard breathing, and this should be considered an emergency
situation. The Plan denied your request. The Plan says ambulance services provided without transport are not
covered by Medicare.

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 May 23, 2021. 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 May 23, 2021.
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. You say that this service can provide pain relief. The Plan denied your request. The Plan says the requested service has not been proven effective as standard treatment of sacroiliac joint pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that radiofrequency ablation of the sacroiliac joint was requested. 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 you have chronic bilateral sacroiliac joint pain and diagnosis of sacroiliitis. Sacral ablation for the treatment of sacroiliac joint pain is considered experimental and investigational. Therefore, the requested service 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a
gastroenterologist on December 10, 2020.

You asked the Plan to waive the copayment for the gastroenterology visit. You say that you are not able to
afford this bill. 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 $30
copayment for visits with a specialist.

You have been asked to pay a $30 copayment for the gastroenterology visit. The gastroenterology visit falls
within the visits with a specialist 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
the office visit you had with a gastroenterologist on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5284).
You asked the Plan to pre-approve the dental service. You say that not replacing that tooth is causing other
issues with your mouth and jaw. You say that your other teeth are moving out of place, causing mouth and jaw
pain. You say that you are not able to chew on that side. You also say that this could cause the other dental
work that has been done to fail, and replacing that work is very expensive. The Plan denied your request. The
Plan says removable unilateral partial denture is not listed as a covered dental service. The Plan also says that
there is no documentation that the requested service is an integral part of a covered procedure or part of a
treatment for neoplastic disease involving the jaw.
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
a removable unilateral partial denture (D5284).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit you had on March 2, 2019, and March 8, 2019, and chest x-rays you had an an outpatient hospital facility on November 12, 2019, and November 25, 2019.
You asked the Plan to waive the copayments for the ER visits and the chest x-rays. You say that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the x-rays, because the allowed amounts for these services ($148.00 each x-ray) is less than your copayment obligation, you are responsible for the full allowed amount for those 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 $75 copayment for emergency room visits and a $200 copayment for x-rays at an outpatient hospital facility.
You have been asked to pay a $75 copayment for the ER visits and a $200 copayment for each of the chest x-rays. 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 the emergency room (ER) visit you had on March 2, 2019, and March 8, 2019, and chest x-rays you had an an outpatient hospital facility on November 12, 2019, and November 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the occupational therapy services you had
at an outpatient hospital facility from May 3, 2021, to May 24, 2021.
You asked the Plan to reduce the copayment for the occupational therapy services. You say that you were told
that occupational therapy was only $20 per session. You said that even though you need more therapy, you
cannot afford more than $20 per session. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan also says that for each date, the allowed amount is less than your copayment
obligation, so you are responsible for the full allowed amount for each date.
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 occupational therapy you receive at an outpatient hospital facility.
You have been asked to pay a $150 copayment for the occupational therapy evaluation. Because these services
occurred at an outpatient hospital facility, the outpatient hospital services copayment of $150 applies. 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 reduce the copayment for the occupational therapy services you had at an outpatient
hospital facility from May 3, 2021, to May 24, 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 you would like the LTACH care approved. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.
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 that there is no evidence that you require services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance (CPT code(s): 64636 and 64635), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the notes do not show that the enrollee had two injections of numbing medicine.
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 services. Our physician reviewer found the record indicates that the enrollee has chronic back pain due to multilevel degenerative disease. The record indicates that the enrollee has had one diagnostic injection with 80% pain relief. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance (CPT code(s): 64636 and 64635), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract eye surgery for the enrollee to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve cataract eye surgery. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no network deficiency for the type of service requested.

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 cataract eye surgery for the enrollee to be provided by an out-of-network (OON) provider.