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

We decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and a miscellaneous vision item (D2799) provided on June 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for eyeglass frames, progressive lenses and a miscellaneous vision item. You say that the provider was listed on the Plan's in-network provider website. The Plan denied your request. The Plan says supplemental eyewear must be obtained from a provider in the Plan's vision vendor network.

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 routine eye exams and supplemental eyewear must be obtained from a provider in the Plan's vision vendor network. Services obtained from vendors outside this network are not covered. 

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, progressive lenses and a miscellaneous vision item have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781) and a miscellaneous vision item (D2799) provided on June 14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
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 manual wheelchair 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 criteria for coverage are not met. Our physician reviewer found the submitted records show that you are
able to ambulate with a walker. You do not require a wheelchair to complete mobility-related self-care tasks.
The criteria for coverage are not met and the requested wheelchair 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia syringe, 60 mg/ml.
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, zoledronic acid.
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 Prolia. Our reviewer says that the requested drug, Prolia, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed one intravenous bisphosphonate therapy, such as zoledronic acid. The reviewer also found that the provided documentation does not support that one intravenous bisphosphonate therapy would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the request for Prolia is not medically necessary as the step therapy criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file shows that the enrollee has not tried and failed the preferred drug. Therefore, we decided that the Plan does not have to pre-approve Prolia syringe, 60 mg/ml.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 22, 2021.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continued care. You say that the enrollee's family feels they could have benefited from more therapy. You say that the enrollee did not receive adequate therapy minutes between October 22, 2021, to October 24, 2021, due to a staffing shortage. You also say that the enrollee's family did not receive the voicemail notifying them of the non-coverage until after the last covered day. The Plan denied your request. The Plan says the request for continued SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 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 the continued care have not been met. Specifically, the file shows that the enrollee does not require daily skilled care. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee does not need skilled nursing care every day that can only be done in a SNF. The Plan states the enrollee is not taking medicine that is given through a vein, they do not need complex wound care, they do not need skilled therapy care every day that can only be done in a SNF, they are at or close to your normal level of function, and their level of function before this hospital stay was needing a lot of help at home. The Plan states it does not appear the enrollee can fully participate in therapy because they are confused and unable to walk.
The Plan states for these reasons, admission to a SNF is not medically necessary at this time and the enrollee's needs can be met with nursing or therapy services provided at home or in long term care.
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 the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is not shown to have a significant decline in function from their baseline. The enrollee is not shown to be able to participate in daily skilled therapy. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services rendered on July 13, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 21 for inpatient hospital; however, the file shows that the services were performed in the outpatient setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the monitoring services rendered on July 13, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625) provided to the enrollee on June 24, 2021.

You asked the Plan to pre-approve the service. You say that the service was medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated in the peer-reviewed literature. The Plan states the use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide a clear long-term benefit over standard treatment for chronic sacroiliac pain.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested SI joint RFA 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625) provided to the enrollee on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rhythm monitor (CPT code 33285), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee did well on their stress test and no arrhythmia was noted; therefore, the Plan states they cannot authorize this request at this time.

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 service. Our physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ischemic cardiomyopathy (ICM). The enrollee has a history of paroxysmal atrial fibrillation, with previous nuclear stress test and ambulatory electrocardiogram (ECG) monitoring which have been unremarkable. In summary, there is insufficient documentation to support the medical necessity for insertion of an ICM in this enrollee's clinical management. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac rhythm monitor (CPT code 33285), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for metabolic encephalopathy, hyperkalemia, bradycardia after missing scheduled dialysis for about a week. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 this patient 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has
a past medical history of osteoarthritis and alcohol abuse and has had a functional decline while living in the
home. The patient has been treated for alcohol withdrawal as an outpatient and for a urinary tract infection as
an outpatient. There is no documentation of medical need for inpatient medical care. There are no complex
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 this patient 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of extremity veins (93970) provided on June 28, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you already paid a copayment at the time of service, and now you are being billed an additional $95 for this service. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. The Plan contacted the provider and verified that you paid $15 on the date in question. Ultrasounds require a $110 copayment. $95 is the difference between what you paid previously and the full copayment 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 $110 copayment for radiological diagnostic services (not including x-rays). You have been asked to pay a $110 copayment for the ultrasound. An ultrasound falls within the radiological diagnostic services (not including x-rays) benefit category. The bill you provided on appeal shows that you previously paid $15, and you are now asked to pay an additional $95 ($15 + $95 = $110). 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 ultrasound of extremity veins (93970) provided on June 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (95941) provided April 30, 2021.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95941 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "I" and is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (95941) provided April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the denosumab injection (J0897) and the chemotherapy administration, subcutaneous or intramuscular (96401) provided on December 29, 2020.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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% coinsurance for each Medicare Part B drug. Additionally, you must pay a $45 copayment for a specialty physician visit.
You have been asked to pay $282.60 ($237.60 + $45) for the Medicare Part B drug injection and the chemotherapy administration provided by a specialist. This is the Plan's allowed amount of $1,188 x 20% coinsurance=$237.60 for the Medicare Part B drug injection provided. Additionally, this amount includes a $45 copayment for the chemotherapy administration provided by a specialty physician. 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 cost share for the denosumab injection (J0897) and the chemotherapy administration, subcutaneous or intramuscular (96401) provided on December 29, 2020