Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 8, 2021.
You asked the Plan to pre-approve the continued SNF care. You say that you are not ready to be discharged at this time. The Plan denied your request. The Plan says you have reached your maximum recovery potential and no longer require daily skilled care to maintain your condition.
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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male admitted to the SNF with COVID pneumonia and bipolar disorder. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for depression and bipolar disorder. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By the dates in question, the beneficiary was at a supervision to independent level with functional mobility including gait to 150 feet with no assistive device. The beneficiary was independent with daily living activities. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous process devices procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee has low back and leg pain and needs this procedure. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices
remain 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous process devices procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you cannot make do on your own. The Plan denied your request. The Plan says your needs are 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you do not have skilled nursing or therapy needs. You do not meet the severity of illness or intensity of service criteria for inpatient care in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist device (L8702) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the orthotic device. You say that you really need to try to get movement back in your hand and arm so you can function in life like you once were. 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. This device does not have proven benefit and is considered experimental and investigational.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist device (L8702) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve OON services. You say that it is too far to drive to see an approved
provider. The Plan denied your request. The Plan says you do not have an existing relationship with the
requested provider.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The file shows that a consultation with an ear, nose, and throat (ENT) provider was requested. The requested
provider in this case is not a network provider with the Plan. The Plan has network providers available who can
provide the services at issue in this appeal. We were able to confirm that the Plan has contract providers located
within reasonable distance and travel time from your home who can provide the services at issue.
We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that
the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable but requires additional short-term acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility for the time being. Transfer to a lower level of care may be considered when treatment has completed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable


We decided that the Plan does not have to pay for the eyeglasses (V2020, V2750, V2303) provided on February 24, 2021.

You asked the Plan to pay for the eyeglasses. You say that there was a mistake on your first set of glasses, and they needed to be replaced and fixed before you brought them home. The Plan denied your request. The Plan says they have paid your full $250 allowance, and the remainder of the cost is denied as your responsibility. You have only been billed for the one pair of eyeglasses that you took home, but the cost exceeds your maximum allowance for routine vision eyewear.

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 up to $250 per calendar year for routine eyewear. If the eyewear you purchase costs more than this allowance, you pay the difference.

We looked at the file and the Plan's rules. The total billed cost of the eyeglasses was $329. The Plan paid $250 for the eyewear, and you are being asked to cover the remaining cost of $79. Based on this information, we decided that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the eyeglasses (V2020, V2750, V2303) provided on February 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound study provided on April 29, 2021.
You asked the Plan to waive the copayment for an ultrasound study. You say that you thought that the ultrasound would be included in the specialist copayment. 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 diagnostic mammograms and an $85 copayment for radiological diagnostic services. You have been asked to pay an $85 copayment for an ultrasound study. An ultrasound study falls within the
outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound study provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevating system.
You asked the Plan to pre-approve the requested services. You say that this is the only way you are able to
reach food in your refrigerator. The Plan denied your request. The Plan says seat elevating systems are not
medical in nature.
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only
covered under certain medical indications.
We looked at the file, and Medicare rules. A power seat elevation feature is not primarily medical in nature.
Based on this information, we decided that Medicare rules for coverage of the requested services have not been
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevating system
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.
You asked the Plan to pre-approve the skilled nursing services. You say that the enrollee's family was only given two days notice of the termination of insurance coverage, which is insufficient for them to make alternate arrangements for the enrollee. The Plan denied your request. The Plan says the enrollee has made little to no progress. The Plan also says that the enrollee's needs are custodial at this time.
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 the skilled nursing services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation, two extractions, bone replacement graft for
ridge preservation, and preventive procedure provided on February 26, 2021.
You asked the Plan to pay for the consultation, extractions, bone replacement graft, and preventive procedure.
You say that no one advised you that the treating provider was out-of-network. You also say that you feel you
should not be held responsible for these charges. The Plan denied your request. The Plan says the maximum
allowed for the 2021 calendar year has been met.
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 Plan offers a $2,000 allowance for
covered preventive and comprehensive services. The contract says that you will be responsible for any costs
above the $2,000 yearly maximum benefit allowance. The record shows that you met the annual maximum
benefit on March 17, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that
the Plan does not have to pay for the consultation, two extractions, bone replacement graft for ridge
preservation, and preventive procedure provided on February 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 an Intracept procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the out-of-network (OON) provider on May 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 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. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the out-of-network (OON) provider on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right total hip arthroplasty (27130).

You asked the Plan to pre-approve a right total hip arthroplasty. You say that this requested procedure is
medically reasonable and necessary. The Plan denied your request. The Plan says there is no documentation of
conservative therapy as required by the Medicare rules.

The Plan follows Medicare rules. Medicare rules say that there must be evidence of an unsuccessful nonsurgical
medical management before the hip arthroplasty will be approved.

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 right total hip arthroplasty. Our
reviewer says that the requested procedure is not medically reasonable and necessary according to Medicare
rules. Our physician reviewer found the criteria for hip replacement surgery have not been met. Specifically,
there is no documentation of a recent trial and failure of physical therapy for hip pain as required by Medicare
rules.

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 right total hip arthroplasty have not been met. Therefore, we decided that the
Plan does not have to pre-approve a right total hip arthroplasty (27130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on June 2, 2021.
You asked the Plan to pay for the dental service. You say that you needed this x-ray for your diagnosis. You say that you had it done due to a crown that needed to be recemented. You also say that you needed a cleaning. The Plan denied your request. The Plan says 1 set of bitewing x-rays is covered per plan year. 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 bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a set of bitewing x-rays that you received on February 22, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist services provided on April 8, 2021.

You asked the Plan to waive the coinsurance for specialist services. You say that you double checked with the provider that they were in-network and they assured you that they were. 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 30% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You received specialist services on April 8, 2021, from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $570.69 and 30% of that is $171.20.

You have been asked to pay the total coinsurance amount of $171.20 for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on April 8, 2021.