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

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 24, 2021.  You asked the Plan to pay for the dental service. You say that you are being charged for your first annual oral comprehensive evaluation. You say that this is included in your insurance. You say that you paid $43 after your visit. You say that you should not have had to pay this. You also say that your insurance should cover this. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. 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, the requested items or services are not among those covered under this benefit. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 26, 2020, less than 3 years ago. Additionally, the record shows that the $43 that you paid on the date of service was a balance on the account from a previous date of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) provided on August 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that you had called the Plan prior to receiving the services and was told the provider was participating. You have established yourself with this provider and would like to continue seeing them. 

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 integrated biopsychosocial assessment (90791) provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) and Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136).  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation of the cataract having an impact on your activities of daily living.  The Plan must follow Medicare rules. Medicare rules say that cataract extraction may be covered if LCD criteria have been 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 requested services are not considered medically reasonable and necessary in this case. The record indicates that you have a left eye senile cataract and have vision of 20/40-2 in the left eye. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) and Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and endodontic therapy (D3320) provided on June 8, 2021.  You asked the Plan to pay for a limited oral evaluation, and endodontic therapy. You say that you were told that part of the services would be covered. The Plan denied your request. The Plan says the limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every calendar year. The endodontic therapy is not a covered benefit.  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.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and endodontic therapy have not been met. Specifically, the record shows that you had exceeded the frequency limit for the limited oral evaluation prior to this service on June 2, 2021. Additionally, endodontic therapy is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and endodontic therapy (D3320) provided on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a bone marrow biopsy provided on June 25, 2021.  You asked the Plan to waive the copayment for a bone marrow biopsy. You say that your services should be covered in full. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities.    You received a bone marrow biopsy at an outpatient hospital facility on June 25, 2021. A bone marrow biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment.   You have been asked to pay a $150 copayment for a bone marrow biopsy. A bone marrow biopsy 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 a bone marrow biopsy provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous implant for the enrollee.  You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted.  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 implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that these interspinous distraction devices are experimental. More research is needed to show safety and efficacy.  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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous implant for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 29, 2021, to July 10, 2021.  You asked the Plan to waive the copayment for a SNF stay. You say that it was never communicated to you that you would owe charges past a certain number of days. 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 $0 copayment for days 1-20 and a $184 copayment for days 21-100, per benefit period, for SNF care.   You had a SNF stay from June 29, 2021, to July 10, 2021. The record shows that you had previous SNF stays for a total of 22 days within the same benefit period. Therefore, you are responsible to a $184 copayment for days 23-33 (June 29, 2021, to July 9, 2021). However, you are only being asked to pay $1,936.98, which is less than the total copayment amount.   You have been asked to pay $1936.98 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from June 29, 2021, to July 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Jaco V2 robotic arm (E1399).  You asked the Plan to pre-approve the Jaco V2 robotic arm. You say that this would aid in your daily activities. The Plan denied your request. The Plan says this is not a covered item.  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 Jaco V2 robotic arm. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found medical records do not document details of prior physical and occupational therapy that has been trialed and failed for the enrollee's condition. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.   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 Jaco V2 robotic arm have not been met. Therefore, we decided that the Plan does not have to pre-approve a Jaco V2 robotic arm (E1399).
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve additional OT visits.  You asked the Plan to pre-approve additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says that additional OT is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional OT visits. Our reviewer says that additional OT is medically necessary. Our physician reviewer found that based on the available records the present request for occupational therapy services is to teach the enrollee safe and proper use of a motorized wheelchair. This appears to be a new device for the enrollee with documentation that the motorized wheelchair will improve the enrollee's mobility, social interaction and quality of life. The records do not document that the enrollee has ever been trained on the use of a motorized wheelchair in the past. This request for occupational therapy for motorized wheelchair training appears to meet Medicare criteria for coverage. Based on the medical records provided there is documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional OT visits have been met. Therefore, we decided that the Plan has to pre-approve additional OT visits.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that records do not show that the enrollee has had this type of pain and impaired function for at least 3 months.  The Plan must follow Medicare rules. Medicare rules say that facet joint injections are covered if LCD criteria have been 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 requested services are not considered medically reasonable and necessary in this case. There is other pathology here which may be the source of the enrollee's pain. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 27, 2021.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on April 19, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Ferric Carboxymaltose (iron) Injections.  (J1439) provided on July 19, 2021, and July 26, 2021.  You asked the Plan to waive the coinsurance for Medicare Part B Drugs. You say that the services should be covered as you feel the provider is only charging more because they are now considered a specialist. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services rendered.  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 Medicare Part B prescription drugs, specifically drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services.   You have been asked to pay a 20% coinsurance for 2 Medicare Part B Drug Injections (The combined allowed amount for both is $1,845, 20% of that is $369). Iron injections fall under the Medicare Part B prescription drugs 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 coinsurance for the Ferric Carboxymaltose (iron) Injections.  (J1439) provided on July 19, 2021, and July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left above the knee definitive prosthesis with advanced components.  You asked the Plan to pre-approve knee prosthesis with advanced components. You say that the enrollee would like to get to a K3 level of ambulation. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.  The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files.  Medicare says that a microprocessor knee (L5856), knee-shin system, fluid stance dampening (L5848) and a stance phase control (L5828) is covered for beneficiaries whose functional level is 3 or above. An axial rotation unit (L5986) is covered for beneficiaries whose functional level is 2 or above. The request add-on components exceed' s the member's current needs. The documentation does not support that the member is a defined K1 functional ambulator or has the potential to reach a K3 functional status in a defined period of time.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee prosthesis with advanced components have not been met. Therefore, we decided that the Plan does not have to pre-approve a left above the knee definitive prosthesis with advanced components.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ten (10) additional PT visits.  You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records, the enrollee appears to have improved with therapy to the point of being able to manage ambulation and basic activities of daily living. Review of the records indicates the proposed physical therapy treatment would be primarily a strengthening program, which does not require the unique skills of a professional therapist. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from June 11, 2021, through July 10, 2021.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services 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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of June 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. 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 June 10, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, her function had plateaued by June 10, 2021, and she did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of June 10, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from June 11, 2021, through
July 10, 2021.