Persius/hicric huggingface dataset:
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 do not have anyone to take care of you. The Plan denied your request. The Plan says the services required are considered custodial.
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 physician reviewer found that you are at a contact guard assist level for standing up, walking using a rolling walker, grooming, and toilet transfers. You are at minimal assist for seated lower body dressing. 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. 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS procedure.
You asked the Plan to pre-approve a CardioMEMS procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental for the enrollee's condition.
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 CardioMEMS procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has Class III heart failure with preserved ejection fraction and is on a high dose oral diuretic regimen with recurrent and recent hospitalization for congestive heart failure (CHF). Management of his heart failure with standard medical therapy has not been effective in keeping him with minimal symptoms and has resulted in several recent acute hospitalizations. CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex regimens to optimize fluid status. 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 CardioMEMS procedure have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging for spinal canal and
contents (72148).
You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria to
qualify for coverage.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the provided records did not clearly describe the enrollee having exhausted physical therapy for
the back pain, nor was there evidence of a red flag diagnosis from physical exam or history to justify earlier use
of MRI. Therefore, this request for an MRI will be considered not medically necessary at this time and based
on the provided documentation.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance imaging for spinal canal and contents (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on May 3, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you feel that the charges are too high and disagree with seniors being charged so much. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on May 3, 2021. The total allowed amount is $2,067 and 20% of that is $413.40. You have been asked to pay the total coinsurance amount of $413.40 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services (88121) provided on May 5, 2021.
You asked the Plan to pay for the cytopathology services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this procedure is 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 pay for the cytopathology services. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the performed cytopathology services are considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of the procedure performed. 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 cytopathology services have not been met. Therefore, we decided that the Plan does not have to pay for the cytopathology services (88121) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services (92012, 92015, 92341, V2020, V2203x2) provided on May 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the out-of-network vision care. You say that the enrollee resides in a nursing and rehabilitation facility and therefore had no say in which provider would administer care. The provider also does not know which patients they will see and is not responsible for obtaining authorization as this is coordinated by the nursing facility. The Plan denied your request. The Plan says the requested services were not urgent or emergent and were provided out-of-network. There is no referral on file for this care, nor were the services pre-approved. Therefore, these services are denied.
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 vision services (92012, 92015, 92341, V2020, V2203x2) provided on May 17, 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 Cxbladder Monitor test (0012M) provided on April 13,
2021.
You asked the Plan to pay for the Cxbladder Monitor test (0012M). You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for Cxbladder
testing are non-covered.
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the
Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the resin based composite filling (D2391) provided on June 14, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that you advised the dentist you wanted a silver filling so that you would not have to pay out of pocket. You say that you were told there was a copayment. You say that when you got home you called the dental office and were advised that you received a white filling instead of a silver filling. The Plan denied your request. The Plan says the claim was processed correctly. The Plans says that they pay only the amount that it would have paid to restore the tooth with amalgam. The Plan also says you are responsible for the difference in cost.
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 fillings are covered, if you select a more expensive service than is customarily provided, the Plan pays for that service at the rate of the less expensive service. You are responsible for the difference. Therefore, we decided that the Plan does not have to pay an additional amount for the resin based composite filling (D2391) provided on June 14, 2021.
Your complaint about the upgrade charge for a resin-based filling 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. If the provider bills you for the upgrade which you state you did not receive, please contact the Plan directly regarding this issue
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425) provided on April 7, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that
you use a wheelchair and were unable to get into a car and there was not a wheelchair accessible vehicle that
was available to move you back to the rehabilitation center. The Plan denied your request. The Plan says the
ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ambulance service, basic life support, nonemergency
transport. Our reviewer says that the ambulance transport was not medically necessary. Our
physician reviewer found that the documentation does not support that other means of transport (such as
stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. The cited reason
for non-emergency ambulance transfer is that transportation of a wheelchair was necessary. A wheelchair van
would have been an appropriate means of transportation. The documentation does not support that you needed
the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can
provide for safe transport on April 7, 2021. There was no documented need for any BLS or ALS services.
The documentation does not support that the ambulance transport on April 7, 2021 was medically reasonable and 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a mandibular partial denture (D5214) to be provided by a participating provider.
You asked the Plan to pre-approve a mandibular partial denture. You say that you would like approval for the dentures. The Plan denied your request. The Plan says that the benefit maximum for the dental services being requested, has already been exhausted.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to provide an evidence of benefits to show that the enrollee's denture maximum allowance has already been exhausted. Therefore, we decided that the Plan has to pre-approve a mandibular partial denture (D5214) to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology visit provided by a provider who has opted out of the Medicare program provided on May 25, 2021.
You asked the Plan to pay for the dermatology visit provided by a provider who has opted out of the Medicare program. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.
Therefore, we decided that the Plan does not have to pay for the dermatology visit provided by a provider who has opted out of the Medicare program provided on May 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Durolane. Our reviewer says that the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. Our physician reviewer found the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on June 14, 2021.

You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges
because you were not aware you would owe a deductible. 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. Your
contract with the Plan says that there is a $198 copayment which applies to physician/practitioner services,
including doctor's office visits.

You had an office visit on June 14, 2021. The record shows that you had paid $0 toward the $198 deductible
prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $119.51.

The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $198 copayment which applies to physician/practitioner services,
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an
office visit was received on June 14, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for an office visit provided on June 14, 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 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the albuterol provided on June 7, 2021, and July 7, 2021.
You asked the Plan to waive the coinsurance for the albuterol. You say that you did not get 300 units of the drug. 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 20% coinsurance for each Medicare Part B drug. The record shows you received 300 units of albuterol for each date of service. You have been asked to pay $3.06, which is 20% of the allowed amount for each date ($15.30 allowed amount x 20% coinsurance = $3.06). The albuterol falls within the Medicare Part B Prescription Drugs 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 coinsurance for the albuterol provided on June 7, 2021, and July 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on June 11, 2021, by a provider not enrolled in the Medicare program.
You asked the Plan to pay for psychotherapy services. You say that the services at issue should be covered per the Plan's 2021 Evidence of Coverage. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on June 11, 2021, by a provider not enrolled in the Medicare program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clasp addition to existing partial denture (D5660)
provided on May 21, 2021.

You asked the Plan to pay for the clasp addition to existing partial denture (D5660). You say that they did not
ask, and you did not give permission to alter the denture. You say that you shouldn't have to pay for this
company ruining your partial and you cannot afford it. The Plan denied your request. The Plan says the service
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.

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. Therefore, we decided that the Plan does not have to pay for the clasp
addition to existing partial denture (D5660) provided on May 21, 2021.