Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that the enrollee has uncontrolled diabetes. The Plan denied your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin three or more times per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care skilled nursing visits (CPT code
G0299 X 6).

You asked the Plan to pre-approve the home health care skilled nursing visits. You say that the services are
necessary. The Plan denied your request. The Plan says your vital signs, taken by the home health nurse, are
stable. The Plan states your medical condition has not changed recently, you have caregivers available to help
manage your treatment as needed, you have not been taken to the emergency room or re-admitted to the
hospital recently, and you have had no recent falls. The Plan states your records do not support the need for a
skilled nurse to make more visits and if your doctor determines that more home visits are needed, he or she can submit a request for more visits that includes your progress and information supporting medical need.

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 care skilled nursing visits. Our physician reviewer found the documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically 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 home health care skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care skilled nursing visits (CPT code G0299 X 6).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided on June 4, 2021.

You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the facility charges. 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 $30 copayment for specialist services.

Your contract with the Plan also clearly says that you must pay 20% coinsurance for Part B drugs
.
You had a specialist visit on June 4, 2021. Therefore, you are responsible to pay the $30 copayment.
 
You received Medicare Part B drugs on June 4, 2021. The total allowed amount is $6.22 and 20% of that is $1.24. 

The total amount you owe is: $31.24.

You have been asked to pay the total amount of $31.24 for a specialist visit and Medicare Part B drugs. A specialist visit falls within the doctor visits benefit category. Medicare Part B drugs fall within the Part B drugs 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 specialist visit and does not have to waive the coinsurance for Medicare Part B drugs provided on June 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the member has stabilized medically. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on April 7, 2021.
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you would like reconsideration because you experienced a nose bleed and the ambulance was called. The Plan denied your request. The Plan says ambulance response and treatment by emergency medical personnel with no need to transport the individual to a hospital is not a covered benefit.
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 April 7, 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 the ambulance response and treatment without transport (A0998) provided on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on April 8, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you cannot afford the charges. 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 $150
copayment for MRI's.
You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic tests
and therapeutic services and supplies 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 MRI provided on April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from April 29, 2021, through May 10, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that you were assured by the representative that home therapy was covered, and you would have to pay $40 if you went to their location. You say that this should be covered because this is what you were told. The Plan denied your request. The Plan says the copayments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 per day for Medicare-covered physical therapy services from a network provider.

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $160 ($40/visit x 4 visits = $160). Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show the services were not provided by a home health agency. 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 physical therapy provided from April 29, 2021, through May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on May 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 outpatient services provided on May 28, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on April 8, 2021.
You asked the Plan to pay for the dental service. You say that you were advised prior to the work being performed that the services were completely approved. You say that you do not understand how the provider's office could get a pre-approval authorization if the benefit was exhausted. You also say that you do not feel that you do not have any financially obligation in this matter. The Plan denied your request. The Plan says there is a maximum allowance of $1,000 for covered dental services. The Plan also says that the maximum allowance has been exhausted.
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 and core build up is listed as a covered service, the maximum allowance has been exhausted.
The record shows that the Plan paid $235 for dental services you received on March 24, 2021, $132 for dental services you received on March 31, 2021, and $633 for dental services you received on April 26, 2021. $235+$132+633=$1,000. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781) and anti-reflective coating (V2750) provided on June 30, 2021.

You asked the Plan to pay for deluxe frames, progressive lenses and anti-reflective coating. You say that the Plan states one pair of glasses follow cataract surgery. The Plan denied your request. The Plan says the service or item in question is not a covered benefit under any circumstance.

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 contract says that you receive one pair of eyeglasses or contact lenses after each cataract surgery. Tinting, scratch protection or other enhancements to the eyewear are not covered. 

We looked at the file and the Plan's rules. The EOC confirms that Medicare only covers standard frames following cataract surgery. The records show that you purchased the added enhancements, and they are considered upgrades and are not covered benefits of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of deluxe frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781) and anti-reflective coating (V2750) provided on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment ambulance services provided on
April 26, 2021.
You asked the Plan to waive the copayment ambulance services. The Plan denied your request. The Plan says the member has responsibility of $365 for an ambulance ride, which is correct per the member's Evidence of Coverage
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 $365 copayment for ambulance services. You have been asked to pay a $365 copayment for ambulance services. The ambulance services falls within the ambulance 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 ambulance services provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS)
therapy.
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 the criteria for coverage are not met.
The Plan must follow Medicare rules. The rules say that TENS for chronic low back pain is covered when
specific criteria are met and when the beneficiary is enrolled in an approved clinical study meeting specific
requirements.
We looked at the file and Medicare rules. The file shows that the services are not being requested as part of an
approved clinical study. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pre-approve transcutaneous
electrical nerve stimulation (TENS) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee is not adjusting insulin doses regularly.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The medical records do not indicate that the enrollee requires
frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 a continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional hours of home health aide care per week.

You asked the Plan to pre-approve additional home health aide services. You say that the enrollee does not live with you. You say that the enrollee lives on their own. The Plan denied your request. The Plan says the additional home health aide hours are not medically reasonable or necessary
.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health aide services. Our reviewer says that 3 additional hours per week of home health aide care is not medically necessary.

Our physician reviewer found that in this case, the documentation does not support that the enrollee requires additional services of a home health aide (HHA) to provide treatment that is medically necessary. The reviewer found that the enrollee does not require additional hours of HHA services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that the current 3 HHA hours are adequate to care for the enrollee and if they require more assistance with household chores services can be obtained from a non-skilled individual. The requested additional home health services are not medically 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 home health aide services have not been met. Specifically, the file does not show that the enrollee requires additional hours of HHA services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Therefore, we decided that the Plan does not have to pre-approve 3 additional hours of home health aide care per week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the parenteral nutrition.
You asked the Plan to pre-approve the parenteral nutrition. You say that these therapies for end-stage renal disease (ESRD) patients are usually deemed medically necessary by physicians to correct protein calorie malnutrition, reduce hospitalizations and achieve better outcomes for the patients. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the parenteral nutrition have not been met. You are able to take food by mouth. Medicare says that food by vein is only covered when you cannot take food by mouth because your gut does not work. Therefore, we decided that the Plan does not have to pre-approve the parenteral nutrition.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ankle surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve ankle surgery. You say that you would like to have this surgery with this OON provider. The Plan denied your request. The Plan says the requested services can be provided by a network 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 ankle surgery to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on February 19, 2021, and April 13, 2021.

You asked the Plan to waive the copayments for ambulance services. You say that the provider does not offer financial assistance. 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 $250 copayment for ambulance services. 

You received ambulance services on February 19, 2021. Therefore, you are responsible to pay the allowed amount of $212.25, which is less than the $250 copayment.

You received ambulance services on April 13, 2021. Therefore, you are responsible to pay the $250 copayment. 

The total amount you owe is: $462.25. 

You have been asked to pay the total copayment amount of $462.25 for ambulance services. Ambulance services fall within the ambulance 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 copayments for ambulance services provided on February 19, 2021, and April 13, 2021.