Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received on January 6, 2021.

You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you feel like your copay assistance program through the drug company should have paid this. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that if you feel this cost sharing should have been paid by another entity, you will need to contact them directly.

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 20% coinsurance for chemotherapy drugs. 

You have been asked to pay 20% coinsurance for the chemotherapy drugs. 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 coinsurance for chemotherapy drugs you received on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravascular ultrasound (37253) provided on December 10, 2020.

You asked the Plan to pay for the intravascular ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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, the CPT Code Manual definition of code 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the intravascular ultrasound. Our reviewer says that COT code 37253 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include sufficient documentation to validate that an Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) was performed on December 10, 2020, therefore this service cannot be verified. The National Correct Coding Initiative Policy Manual has specific guidelines defining CPT code 37253. This description was not documented in the operative report. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intravascular ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the intravascular ultrasound (37253) provided on December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz tablets.

You asked the Plan to pre-approve Xeljanz. You say that you revoked your hospice benefit and this drug is of critical importance to you. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits.

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 Xeljanz tablets.

Benefits for Xeljanz 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).
You asked the Plan to pre-approve a portable ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition. 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 portable ventilator. Our reviewer says that the requested item is not medically necessary in this case. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease (COPD) requiring supplemental oxygen but there is no
documentation of carbon dioxide (CO2) retention. Furthermore, even if CO2 retention were demonstrated, Medicare does not cover a home ventilator when used as a bi-level positive airway pressure (BiPAP) device. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require a transfer to LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional trips. You say that you have no way to get to your appointments. The Plan denied your request. The Plan says additional trips are not a covered benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The records show that you have used 20 trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation.
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 IRF admission and services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on March 29, 2021.

You asked the Plan to pay for the therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, this code has a status code of "B". A status code of B means that this code is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection, expandable controller, and expandable controller harness.

You asked the Plan to pre-approve electronic connection, expandable controller, and expandable controller harness. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are only covered for certain indications. 

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 electronic connection, expandable controller, and expandable controller harness. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee is independent with feeding, grooming, dressing, bathing, and meal preparation. This indicates that the enrollee has adequate upper extremity function to operate the power options with their own switches. Therefore, the enrollee does not meet criteria for the requested items.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electronic connection, expandable controller, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection, expandable controller, and expandable controller harness.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2740) provided on April 1, 2021.
You asked the Plan to pay for the dental service. You say that the service was denied because you already reached the maximum count. You also say that you have only received 1 crown this year. The Plan denied your request. The Plan says that the maximum benefit of up to 2 restorative services per visit every year has been exceeded.
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. Your contract with the Plan does not say in clear and accurate terms the conditions in which the dental services are or are not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Specifically, the Evidence of Coverage does not clearly inform the conditions in which restorative services, including a crown, would be covered. Therefore, we decided that the Plan has to pay for the crown (D2740) provided on April 1, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
September 24, 2019, to September 27, 2019.
You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not agree with
the decision of the insurance claim because you paid more than your out of pocket expenses. The Plan denied
your request. The Plan says you have been charged the correct cost sharing 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 $295
copayment each day for days 1 to 6 for inpatient hospital care. You have been asked to pay a $295 copayment each day for days you received inpatient hospital services. You
had two days of inpatient hospital services, for a total of $590 (2 days x $295 per day = $590). Inpatient
hospital services fall within the Inpatient Hospital Care benefit category.
The Plan contract also clearly says that there is an in-network maximum out of pocket expense of $4,500. The record shows that, although the out of pocket expenses were met at the end of 2019, there was a recoupment in April of 2020 for one of the claims. Therefore, the 2019 out of pocket expenses were no longer met. 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 inpatient hospital services provided from September 24, 2019, to September 27, 2019.
Your complaint about the customer services you received from the Plan 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has exceeded the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108
x3, E2331) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.

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 accessories. Our reviewer says that
the requested accessories are not considered medically reasonable and necessary in this case. Our physician
reviewer found the seat elevator (E2300) does not primarily serve a medical purpose and cannot covered. The
criteria is not met for the attendant control (E2331) as the guidelines state that "if an attendant control (E2331)
is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered." The
Luci Model 101 and memory seat program (K0108) exceed the enrollee's medical need, as they do not serve a
primarily medical purpose, and do not meet the definition of medical necessity. The R Net Module (K0108) is
not covered as this code must not be used for any component or feature of an expandable controller at the time
of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance
for codes E2377/E2376 plus E2313.

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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2300, K0108 x3, E2331) for the enrollee.
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 you cannot function on your own and need further assistance. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of 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 SNF care. Our reviewer says that admission to an SNF is not medically reasonable and necessary in this case. Our physician reviewer found that you have no documented daily skilled nursing needs and do not require daily skilled therapies in an inpatient setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the corneal topography services provided on April 16, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the clinical effectiveness in the setting of cataracts have not been demonstrated in peer-reviewed literature.

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 the services provided. Our physician reviewer found that in this case, the record indicates the enrollee has cataract and Fuch's corneal dystrophy. The record does not indicate that the enrollee is undergoing cataract surgery. The record show that the indication for the requested service is Fuch's corneal dystrophy. The enrollee is being treated for this indication. The requested service is not medically necessary or reasonable, as defined by Medicare rules, for the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the corneal topography services provided on April 16, 2021.