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

We decided that the Plan does not have to pay for refraction provided on June 4, 2021.

You asked the Plan to pay for determination of refractive state (92015). You say that you were told the provider was an in-network provider. The Plan denied your request. The Plan says the eye refraction service was a medical vision check not a routine screening.

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 eye refractions during a routine exam, performed by a preferred provider.

We looked at the file and the Plan's rules. The refraction performed was a medical vision check and not provided by the preferred provider. Based on this information, we decided that the Plan's rules for coverage of determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for refraction provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the continuous positive airway pressure
(CPAP) device rental provided April 19, 2021, to May 19, 2021.

You asked the Plan to waive the deductible for the CPAP device rental. You say that you would like this
deductible waived. The Plan denied your request. The Plan says the cost share has processed correctly in this
case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $300 in-network deductible which applies to durable medical
equipment.

The item or service you asked the Plan to waive the deductible for falls within the benefit category durable
medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$300 in-network deductible which applies to durable medical equipment.

This cost sharing is a contractual obligation that had not been met at the time the CPAP device rental was
received on April 19, 2021 to May 19, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for the continuous positive airway pressure (CPAP) device rental provided April 19, 2021, to May
19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of vein wound compression system provided June 8, 2021, to June 29, 2021.
You asked the Plan to waive the copayment for the application of vein wound compression system. You say that you were told this procedure would be covered. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 surgery services at an outpatient hospital.
You have been asked to pay a total cost share of $750 for the application of vein wound compression system
($150 copayment x 5 procedure days). This service falls within the surgery services at an outpatient hospital
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 application of vein wound
compression system provided June 8, 2021, to June 29, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ketamine.
You asked the Plan to pre-approve Ketamine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ketamine. Our reviewer says that the documentation does support that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of major depressive disorder, recurrent, severe, without psychotic features. Based on the medical records provided and the Medicare-approved major drug compendia there is documentation (although the strength of the evidence is low) that supports that the Ketamine is medically reasonable and necessary for the enrollee's severe recurrent depression. The documentation supports that Ketamine is safe and effective for the enrollee's severe recurrent depression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine have been met. Therefore, we decided that the Plan has to pre-approve Ketamine.
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 pre-approve a knee orthosis (L1851).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate any of the covered problems.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a diagnosis of knee arthritis. The record does not indicate that the enrollee has had a recent injury or surgery. The record does not indicate the presence of knee instability. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not listed as a preferred drug on the health plan's preferred drug list.

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 the drug. Our reviewer says that the requested drug is not medically reasonable and necessary, and the request has not followed step therapy guidelines. Our physician reviewer found the case file does not contain any documentation of a trial and failure of Synvisc, Synvisc-One, and Orthovisc. The documentation does not support that these drugs would likely be less effective and/or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 29, 2021, to February 3, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically necessary. The Plan denied your request. The Plan says that these services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee was admitted with congestive heart failure exacerbation and bilateral airspace disease on chest x-ray. The enrollee has a history of coronary artery disease. Our reviewer found that the enrollee is anemic. The record in its totality documents that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. Our physician reviewer also found that the elements of the coverage rule are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 29, 2021, to February 3, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are appears to be some concern that these devices are not as effective as surgical decompression, and could lead to higher rates of re-operation.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the SNF stay provided from January 1, 2021, through February 28, 2021.
You asked the Plan to reduce the cost for the SNF stay. You say that she had 14 days of mandatory quarantine which should have been paid in addition to the skilled nursing days. You say that the rules say she would 100 skilled days followed by 60 days of private pay but only 68 days were approved. The Plan denied your request. The Plan says the copayment applied 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). The enrollee's contract with the Plan clearly says the most enrollees will have to pay out-of-pocket for in-network covered Part A and Part B services in 2021 is $6,300.
The enrollee has been asked to pay $6,300 which is less than the standard copayment for the SNF stay because the enrollee met the maximum out-of-pocket. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the cost for the SNF stay provided from January 1, 2021, through February 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 9, 2021 by an out-of-network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 laboratory services provided on June 9, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 16, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the six-month rental of a cough stimulating device (E0482).
You asked the Plan to pre-approve the six-month rental of a cough stimulating device. You say that the service is medically necessary. The Plan denied your request. The Plan says that the LCD criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that that mechanical in-exsufflation devices (E0482) are covered for beneficiaries who meet all of the following criteria; They have a neuromuscular disease (refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses), and This condition is causing a significant impairment of chest wall and/or diaphragmatic movement, such that it results in an inability to clear retained secretions. 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 six-month rental of a cough stimulating device. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has a neuromuscular disease (ALS), and their condition is causing a significant impairment of chest wall and/or diaphragmatic movement, such that it results in an inability to clear retained secretions. 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 six-month rental of a cough stimulating device have been met. Therefore, we decided that the Plan has to pre-approve the six-month rental of a cough stimulating device (E0482).
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 electric tricycle (E1399) and lock (E1399), provided on
April 8, 2021.
You asked the Plan to pay for the electric scooter and lock. You say that the items are medically necessary. The
Plan denied your request. The Plan says the requested item is not primarily medical in nature and is being
requested for transportation purposes outside of your home. In addition, there is no indication prior
authorization was obtained.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pay for the electric tricycle (E1399) and lock (E1399), provided on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is not doing well, his mobility is compromised and he requires treatment. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. 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 the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 27, 2021, by an out-ofnetwork
provider.
You asked the Plan to pay for the office visit. You say that the Plan referred you to this provider. The Plan
denied your request. The Plan says you did not request prior authorization as required.
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 service at issue in this appeal. The Plan did not pre-approve the service
at issue. The referral you mentioned expired in 2018. 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 office visit provided on
April 27, 2021, by an out-of-network provider.
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 stay 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 daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your 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.