Persius/hicric huggingface dataset:
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 are not strong enough to go home. The Plan denied your request. The Plan says that the services you require can safely be received at a different 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network consult for a knee replacement.  You asked the Plan to pre-approve an out-of-network consult for a knee replacement. You say that first you were told you would need a knee replacement then you were told you do not. You say that you are requesting a second opinion from an outside source regarding the knee replacement. The Plan denied your request. The Plan says in-network specialists are available.  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 an out-of-network consult for a knee replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5212).  You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you do not have teeth which makes it difficult for you to eat. You also say that the dentures move around why you are trying to eat. The Plan denied your request. The Plan says these services are 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 a complete maxillary denture (D5110) and a mandibular partial denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  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 Eliquis.        Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit provided to the enrollee on October 12, 2021.  You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says no services were authorized for this provider.  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 an office visit provided to the enrollee on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power wheelchair.  You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power standing feature are non-covered. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the spine procedure (22899).  You asked the Plan to pre-approve the spine procedure (22899). You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional conservative methods. You say that the Intracept procedure is medically necessary and the most effective treatment at this time. The Plan denied your request. The Plan says this procedure is considered experimental and investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the spine procedure (22899). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure is experimental. More research is needed to show safety and efficacy.     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 spine procedure (22899) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine procedure (22899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on July 15, 2021.  You asked the Plan to pay for the eyeglasses. You say that you never had to pay for anything. The Plan denied your request. The Plan says you have exceeded your eyeglass benefit limit. Your eyeglass benefit is not available again until after March 13, 2022.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every 2 calendar years.   We looked at the file and the Plan's rules. The file shows that you lased used your $250 eyeglass benefit on March 13, 2020. Since the eyeglass benefit is every 2 calendar years, your benefit is not available again until after March 13, 2022. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on  July 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) (G0299) and services of home health aide (HHA) (G0156).  You asked the Plan to pre-approve the direct skilled nursing services of a RN and services of an HHA. You say that the enrollee would benefit from a HHA to assist with bathing and other activities of daily living. The Plan denied your request. The Plan says home health and HHA visits are not medically necessary for the enrollee's condition.  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 direct skilled nursing services of a RN and services of an HHA 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 direct skilled nursing services of a registered nurse (RN) (G0299) and services of home health aide (HHA) (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a high frequency chest wall oscillator provided from May 28, 2021, to September 28, 2021.  The enrollee asked the Plan to waive the coinsurance for the oscillator. The enrollee said that the equipment was ineffective and they could not afford the bills. The Plan denied the enrollee's request. The Plan says the correct coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment (DME), including oscillators.   The enrollee has been asked to pay $190.39 for each month of use, which is 20% of the allowed amount for the oscillator ($951.97 allowed amount x 20% coinsurance = $190.39).  The file shows 5 months of use from May 28, 2021, to September 28, 2021, for a total responsibility of $951.95 ($190.39 coinsurance x 5 months = $951.95). The oscillator falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a high frequency chest wall oscillator provided from May 28, 2021, to September 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services received on September 30, 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 the services were not authorized or reported correctly.  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/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for  the services received on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist office visits received on March 15, 2021.  You asked the Plan to waive the copayments for the visits. You say that you feel that you are being taken advantage of. The Plan denied your request. The Plan says the copayment was applied appropriately.  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 specialist office visits.   You have been asked to pay a $40 copayment for the visits. The visits fall within the specialist 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 copayments for specialist office visits received on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the podiatry services received on April 8, 2020 and September 1, 2021.  You asked the Plan to waive the copayment for the podiatry services. You say that these services were medically necessary. The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.  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 $20 copayment for podiatry services.     You have been asked to pay a $20 copayment for each of the podiatry services. The podiatry services fall within the podiatry services 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 podiatry services received on April 8, 2020 and September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided August 11, 2021.  You asked the Plan to pay for the limited oral exam and tooth extraction. You say that services from this provider were covered in previous years. The Plan denied your request. The Plan says these services are not covered because they were performed by a provider who has opted out of Medicare.  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 limited oral exam and tooth extraction when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cytopathology services coded 88121 provided on May 7, 2021.  You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The cytopathology services at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cytopathology services coded 88121 provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a knee orthosis (L1832) provided on May 10, 2021.  You asked the Plan to pay for a knee orthosis. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the case file does not contain documentation of knee instability which is documented by examination showing that the enrollee has objective description of joint laxity.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1832) provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).  You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the member has suffered from this condition for 12 years and has failed 12 months of conservative approaches to treatment. You say that this treatment is considered safe and effective, and the procedure should be approved. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of stabilization device (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interlaminar spacer devices remain experimental. More research is needed to show safety and efficacy.    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 insertion of stabilization device (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on January 9, 2020, to January 11, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment amount. The Plan denied your request. The Plan says the correct copayment has been applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.    You have been asked to pay a $100 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $200 ($100 x 2 days = $200). The correct copayment has been applied to the inpatient hospital stay that was provided. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided by a participating provider on January 9, 2020, to January 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health aide (HHA) or certified nurse assistant (CNA) (S9122) and home visit services (99600) provided from August 11, 2021, to August 20, 2021.  You asked the Plan to pay for the HHA or CNA and home visit services. The Plan denied your request. The Plan says the provider is not certified for Medicare.  The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA or CNA and home visit services have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home health aide (HHA) or certified nurse assistant (CNA) (S9122) and home visit services (99600) provided from August 11, 2021, to August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scan of the head (70544) provided on September 5, 2021.  You asked the Plan to pay for the MRA scan of the head. You say that the medical documentation supports the services as they were billed. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scan of the head (70544) provided on September 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nexletol.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 Nexletol.   Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.