Persius/hicric huggingface dataset:
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. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that your goal is to improve your standing ability to
allow you to use a stand lift versus a total lift as used previously. The Plan denied your request. The Plan says
that there are no noted skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient
only status.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a hand-held speech generating device (E2508).

You asked the Plan to pre-approve a hand-held speech generating device. You say that the enrollee needs this device not only to communicate with his family, but also with his medical doctors and care team and anyone else he comes into contact with during every-day life. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for the speech generating device.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a hand-held speech generating device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had a formal evaluation of their cognitive and communication abilities by a speech-language pathologist (SLP). The enrollee's medical condition is one resulting in a severe expressive speech impairment and their speaking needs cannot be met using natural communications methods. Other forms of treatment have been considered and ruled out. The enrollee's speech impairment will benefit from the device. A copy of the SLP's written evaluation and recommendation have been forwarded to the enrollee's treating practitioner prior to ordering the device. The SLP performing the beneficiary evaluation is not an employee of or has a financial relationship with the supplier of the 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 hand-held speech generating device have been met. Therefore, we decided that the Plan has to pre-approve a hand-held speech generating device (E2508).

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health nurse visits (G0299/G0300 x 66).
You asked the Plan to pre-approve home health nurse visits. You say that the service is medically necessary.
The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 home health nurse visits. Our reviewer
says that the service is not medically necessary. Our physician reviewer found 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
health plan has authorized 42 daily visits during this certification period. The approved visits are adequate to
assist you with weekly Trulicity injections and monitor your medical 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 home health nurse visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve the home health nurse visits (G0299/G0300 x 66).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve peripheral nerve block injections of the lateral sacral
branches.

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 peripheral nerve blocks are covered for specific
indications only.

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 records show that you have
sacroilitis. You have received several sacroiliac (SI) joint injections. The requested peripheral nerve block
injections to the lateral sacral branches is considered experimental in nature and 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 peripheral nerve block injections of the lateral sacral branches.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for methylenetetrahydrofolate reductase (MTHFR) gene testing (81291) provided on November 3, 2020.

You asked the Plan to pay for MTHFR gene testing. You say that this is a covered test. The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that MTHFR genotyping is considered investigational and is not a Medicare benefit. 

We looked at the file and Medicare rules. The testing at issue is not a Medicare benefit. Based on this information, we decided that Medicare rules for coverage of MTHFR gene testing have not been met. Therefore, we decided that the Plan does not have to pay for methylenetetrahydrofolate reductase (MTHFR) gene testing (81291) provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 13, 2021.

You asked the Plan to pay for the dental service. You say that the doctor made an appointment for you. You say that the doctor poked your teeth. You also say that you are being charged $25. The Plan denied your request. The Plan says limited oral evaluations are covered once every 6 months. The Plan also says that the frequency limit 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.

Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on March 2, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee from February 10, 2021, to March 8, 2021.
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says SNF care was 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that as of February 10, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of February 10, 2021. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee from February 10, 2021, to March 8, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need SNF care because of your breathing
and heart. The Plan denied your request. The Plan says that you do not require complex daily nursing care that
must be provided in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure performed in an outpatient hospital facility on January 15, 2021.
You asked the Plan to waive the copayment for outpatient surgery. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery in an outpatient hospital facility. 
You have been asked to pay a $400 copayment for outpatient surgery. Outpatient surgery 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 an outpatient surgical procedure performed in an outpatient hospital facility on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2377), the harness upgrade
controller (E2313), and the additional electrical connection (E2311).
You asked the Plan to pre-approve a power wheelchair with several accessories for the enrollee. You say that
the requested power wheelchair and accessories are medically necessary for the enrollee. The Plan denied your
request. The Plan says while the power wheelchair and Medicare allowed accessories are approved, the
expandable controller (E2377), the harness upgrade controller (E2313), and the additional electrical connection
(E2311) are not covered by Medicare.
The Plan must follow Medicare rules. The rules specifically stated the denied accessories are not covered.
Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), the
harness upgrade controller (E2313), and the additional electrical connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on April 27, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you have spoken with a number of
people and no one knows what to do. You also say that you were told by the Plan that the copayment should be
$15. 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 $110
copayment for Medicare-covered radiological diagnostic services, such as a CT scan.
You have been asked to pay a $110 copayment for a CT scan. CT scans falls within the Other Outpatient
Diagnostic Tests - Radiological Diagnostic Services Not Including X-rays 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 CT scan provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to provide additional reimbursement up to the $100 vision benefit for the frames and lens package. We also decided that the Plan does not have to waive the cost-sharing for the remaining cost of the eyewear above the $100 benefit.
You asked the Plan to waive the cost-sharing for the frames and lens package. You say that you do not agree with the cost-sharing applied to this claim. The Plan says that a 50% coinsurance was applied correctly.
We decided that the Plan has to provide an additional $40 reimbursement up to the Plan's $100 vision benefit for the frames and lens package.
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 covers a $100 (combined in and out-of-network) benefit toward the purchase and fitting of eyeglasses and pair of lenses per calendar year. We looked at the file and the Plan's rules. The Plan paid $60 toward the frames and lenses. The Plan contract states that you have a $100 benefit to be used toward the purchase of routine eyewear. Therefore, we decided that the Plan has to provide an additional $40 reimbursement up to the Plan's $100 vision benefit for the frames and lenses purchased April 8, 2021.
We also decided that the Plan does not have to waive the cost-sharing for the remaining cost of the eyewear above the $100 benefit.
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 any amount over $100 retail price for the frames and lens package. Therefore, we decided that the Plan does not have to waive the cost-sharing for the remaining cost of the eyewear above the $100 benefit.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral orthotic appliance (99002) provided on March
16, 2021, by an OON provider.
You asked the Plan to pay for the orthotic appliance. You say that you are requesting reconsideration of
payment. You made the claim and was told it was the wrong code. You went back to the doctor's and got a new
code. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted
providers require prior authorization before services being rendered.
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 intraoral orthotic appliance (99002) provided
on March 16, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift and upgraded electronics (expandable
controller, harness, and electronic connector to 2 power options) for the enrollee.

You asked the Plan to pre-approve a Group 2 Power wheelchair with seat lift and upgraded electronics
(expandable controller, harness, and electronic connector to 2 power options). You say that this power
wheelchair and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan
says while the power wheelchair and Medicare allowed accessories were approved, the seat lift and upgraded
electronics (expandable controller, harness, and electronic connector to 2 power options) are not covered by
Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The seat lift and upgraded electronics (expandable controller, harness, and electronic
connector to 2 power options) are not covered by Medicare. Therefore, we decided that the Plan does not have
to pre-approve these accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit provided on January 11, 2021.

You asked the Plan to waive the copayment for the emergency department visit (99284). You say that you resisted going to the hospital so you should not be charged. The Plan denied your request. The Plan says you were charged this copayment 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 $85 copayment for Emergency Care. 

You have been asked to pay a $85 copayment for the emergency department visit (99284). The emergency department visit (99284) falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster vaccine and immunization administration provided on May 20, 2021.

You asked the Plan to pay for the Zoster vaccine (90750) and immunization administration (90471). You say that you did not know the services should not have been done at the doctor's office. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B benefit.

Medicare does not pay for or provide the Zoster vaccine (90750) and immunization administration (90471). The Plan follows the same rules. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine and immunization administration provided on May 20, 2021.

Benefits for the Zoster vaccine (90750) and immunization administration (90471) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.