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

We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider
on October 11, 2021.
You asked the Plan to pay for prophylaxis. You say that you were unaware you had a frequency limit. The Plan
denied your request. The Plan says the benefit limit for D1110 has already 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. The Plan covers prophylaxis
twice per plan year.
We looked at the file and Medicare rules. Evidence was provided to show that D1110 was provided on January
27, 2021, and June 7, 2021. Based on this information, we decided that the Plan's rules for coverage of
prophylaxis have already been met. Therefore, we decided that the Plan does not have to pay for prophylaxis
(D1110) provided by an out-of-network provider on October 11, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that the requested Ilumya is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Enbrel, Humira, or Skyrizi first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Ilumya. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the case file does not contain documentation of trial and failure of Enbrel, Humira, or Skyrizi. The documentation does not support that Enbrel, Humira, or Skyrizi would likely be less effective, and/or would likely have adverse effects 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on October 12, 2021, by an OON
provider.
You asked the Plan to pay for the wound care. You say that the service was medically necessary. You say you
have an exclusive agreement with the supplier. The Plan denied your request. The Plan says no prior
authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. The records provided
for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan
does not have to pay for wound care provided on October 12, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 82607, 83036, 84443, 85025)
rendered by the out-of-network (OON) provider on March 29, 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 laboratory services (80053, 82607, 83036, 84443, 85025) rendered by the outof-
network (OON) provider on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammography (77063, 76077) provided on July
5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a screening mammography. You say that you do not have the money to pay for
these bills. The Plan denied your request. The Plan says this provider is not a network provider with the Plan
and the services were not referred by a network provider or rendered in an in-network facility. The Plan has
also determined that these services are not urgent or emergent, nor were they approved in advance.
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 a screening mammography (77063, 76077)
provided on July 5, 2021, by an out-of-network (OON) provider.
Your complaint about being potentially misguided by a Plan representative is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on January 8, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you were told that you would only owe a $10 copayment. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for specialist services provided on January 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an X-ray and a nuclear medicine study of
lung ventilation provided on July 8, 2021.
You asked the Plan to waive the deductible for an X-ray and a nuclear medicine study of lung ventilation. You
say that you do not agree with the fact that the Plan has not paid anything toward the claims and that you owe
such a high amount. 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. Your
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies.
You received an X-ray and a nuclear medicine study of lung ventilation provided on July 8, 2021. The record
shows that you had only paid $198.13 toward the $750 deductible prior to receiving the services. Therefore,
you are responsible to pay the remaining deductible balance of $551.87.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time
an X-ray and a nuclear medicine study of lung ventilation were received on July 8, 2021. Therefore, we
decided that the Plan does not have to waive the deductible for an X-ray and a nuclear medicine study of lung
ventilation provided on July 8, 2021.
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. The Plan denied your request. The Plan says IRF admission is not
medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for acute on chronic respiratory failure and obesity related hypoventilation
syndrome. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45385) performed on October 18, 2021.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were not aware there would be a cost for this service. The Plan denied your request. The Plan says the cost-share was assessed in accordance with your outpatient surgery benefit. The Plan says review of the medical records reveals the claim was submitted as a diagnostic colonoscopy due to your history of polyps. A screening, or preventive, colonoscopy is typically performed on patients 50 years or older and who present with no past or present gastrointestinal conditions. However, a diagnostic colonoscopy is performed on patients who present with current gastrointestinal symptoms and who have past or present polyps or gastrointestinal conditions.

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 $175 copayment for Outpatient Surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $175 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the Outpatient Surgery benefit category. Specifically, the ambulatory surgical center copayment applies to the service at issue. 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 diagnostic colonoscopy (45385) performed on October 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide services.  You asked the Plan to pre-approve the requested services. You say that the enrollee is unable to keep up with personal hygiene, meal preparation, and routine house chores. The Plan denied your request. The Plan says the enrollee is not homebound. The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. Custodial care is not covered.   We looked at the file and the rules. The file does not show that the enrollee is homebound. The file also shows that the requested services are considered custodial. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).

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 services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a mobility deficit that impairs the completion of mobility-related activities of daily living (MRADLs) in the home; however, the physician does not support she is at high risk for development of a pressure ulcer. She does not require intermittent catheterization and has no evidence of spasticity. She does not require a ventilator or a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control. Her strength and function in the upper extremities with being set up for eating support that she can control any power options with their individual switches. Furthermore, the documentation is conflicting whether the enrollee has a current power wheelchair or a manual wheelchair. The requested power wheelchair is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments.  You asked the Plan to pre-approve the IVIG treatments. You say that the enrollee was diagnosed with this condition and has had positive outcomes from the treatment. This should be continued to allow for weaning the dosage. The Plan denied your request. The Plan says the records do not show that the diagnostic criteria for chronic inflammatory demyelinating polyneuropathy are met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve the IVIG treatments. Our reviewer says that the requested treatment is not considered medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of chronic inflammatory demyelinating polyneuropathy variant. The medical records provided to do not establish a diagnosis of chronic inflammatory demyelinating polyneuropathy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied.   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 IVIG treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99214) and the psychotherapy service (90833) rendered by the out-of-network (OON) provider on June 11, 2021.

You asked the Plan to issue reimbursement 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 issue reimbursement 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 issue reimbursement for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99214) and the psychotherapy service (90833) rendered by the out-of-network (OON) provider on June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0848, E2606, E2364, E0990, E0973, E2621, E2367, E2321, E2366, E0955, E1002, E2312, E2313, and E2377).

You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair and accessories.

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 a power wheelchair and accessories. Our reviewer says that the enrollee does not meet criteria for the requested power wheelchair and accessories. Our physician reviewer found the reviewed documentation indicates that the enrollee is of paraplegia, onset 2014. The physician office note dated November 2, 2021, does not include a mobility evaluation and a specialty evaluation by a physical or occupational therapist was not provided. The physical examination does not include objective information on the member's strength, range of motion or function. The notes do not show how the member completes mobility related activities of daily living in customary locations throughout the home (bathing, dressing, toileting, grooming and feeding). The physical examination does not describe postural asymmetries to support the requested positioning seat cushion. The physician examination does not show member's ability to complete a weight shift or evidence of pressure ulcer therefore the request for power tilt is not supported. The documentation does not show edema in the lower extremities or a cast or knee brace, therefore, the request for the elevating leg rests is not supported. Per the Medicare LCD for Power Mobility Devices (LCD L33789) the base power wheelchair K0848 does not include power seat options, therefore power tilt (E1002), headrest (E0955) and the electronics (E2313, E2311, E2377) are not supported. The request for the group 3 K0848 power wheelchair does not meet medical necessity criteria. All other accessories or additional items requested to be added to this mobility device are therefore also not covered at this time. 

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 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0848, E2606, E2364, E0990, E0973, E2621, E2367, E2321, E2366, E0955, E1002, E2312, E2313, and E2377).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from April 26, 2021, to June 28, 2021.

You asked the Plan to waive the copayment for wound debridement. You say that you should only owe a $40 specialist copayment per each visit. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received wound debridement at an outpatient hospital facility from April 26, 2021, to June 28, 2021, for a total of 9 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $325 copayment per each visit. The total amount you owe is: $325 (copayment) x 9 (visits) = $2,925.

You have been asked to pay the total copayment amount of $2,925 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 wound debridement provided from April 26, 2021, to June 28, 2021.