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

We decided that the Plan does not have to pre-approve platelet rich plasma injection services (0232T).
You asked the Plan to pre-approve platelet rich plasma injection services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that platelet rich plasma injections coded as 0232T are statutorily non-covered by Medicare. We looked at the file and Medicare rules. In this case, the requested procedure is specifically excluded from coverage by Medicare. Based on this information, we decided that Medicare rules for coverage of platelet rich plasma injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma injection services (0232T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 4, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges. 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 $50 copayment for specialist visits. 

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls 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 copayment for a specialist visit provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on May 25, 2021.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you were not informed that you would owe a copayment for outpatient services. 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 $100 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.
You received a spinal canal injection at an outpatient hospital facility on May 25, 2021. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery and other medical 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 spinal canal injection provided on May 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that you would like this claim to be approved for coverage. The Plan denied your request. The Plan says you do not meet the required criteria that makes you eligible for these benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a single supported porcelain/ceramic crown (D6058), provided by an out-of-network provider on April 1, 2021.

You asked the Plan to pay for a single supported porcelain/ceramic crown. You say that you should not have to change your dentist because Medicare says so. The Plan denied your request. The Plan says these services are not covered due to the provider being out-of-network.

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 a single supported porcelain/ceramic crown (D6058), provided by an out-of-network provider on April 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 12, 2020.
You asked the Plan to pay for laboratory 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 12, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion with an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted provides no additional information that justifies this request.

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 a second opinion with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a therapeutic injection provided from May 28, 2021, to May 31, 2021.

You asked the Plan to waive the copayment for a therapeutic injection. You say that you were not informed that you would owe an emergency room copayment for the services. 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 $100 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

The record shows that you received a therapeutic injection at an outpatient hospital facility on May 28, 2021, to May 31, 2021. Therefore, you are responsible to pay the $100 copayment. 

You have been asked to pay a $100 copayment for a therapeutic injection. A therapeutic injection falls within the outpatient surgery and other medical 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 therapeutic injection provided from May 28, 2021, to May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).

You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. The Plan denied your request. The Plan says you do not meet the required criteria that makes you eligible for these benefits.

The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system.

You asked the Plan to pre-approve a CGM system. 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. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care, a nutritionist, and physical therapy at
home.
You asked the Plan to pre-approve the home health care, a nutritionist, and physical therapy. You say that you
would like to appeal these services. The Plan denied your request. The Plan says the Plan was not provided
with the required physician's order or supporting medical information.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met. Medicare rules also say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Without any information from a medical professional supporting the
need for the requested care, we decided that Medicare rules for coverage of the home health care, a nutritionist,
and physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve
home health care, a nutritionist, and physical therapy at home
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 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 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 did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of October 23, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for skilled nursing facility (SNF) services you received at an out-of-network facility from January 23, 2021, to February 6, 2021.
You asked the Plan to waive the coinsurance for the out-of-network SNF services. You say that this service was pre-approved. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% coinsurance for out-of-network skilled nursing facility services. You have been asked to pay 40% coinsurance for the out-of-network SNF services. The records show that the facility where you received these services is an out-of-network facility with the Plan. 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 skilled nursing facility (SNF) services you received at an out-of-network facility from January 23, 2021, to February 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that you believe your denial should be appealed because it is something you need 3-4 times a year. You also say the alternative would be more costly. The Plan denied your request. The Plan says you have exhausted your maximum benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on June 24, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.

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 first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network general surgeon.
You asked the Plan to pre-approve these services. You say that this physician performed your gastric bypass surgery three years ago and you were pleased with the results. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network general surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair (K0007).

You asked the Plan to pre-approve a wheelchair. You say that you need a second chair for the top floor of your home. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. 

We looked at the file and Medicare rules. The record shows that you currently have a wheelchair. A second wheelchair is not covered. Based on this information, we decided that Medicare rules for coverage of a wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a wheelchair (K0007).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee
no longer requires skilled services on a daily basis.

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.

Continued SNF services beyond October 24, 2021, were requested. 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 were at a moderate
assist level for sitting up, minimal assist for standing up and walking, setup for eating, and at a supervision
level for shower chair transfers. The enrollee does not have documented skilled nursing needs. You do not have
documented skilled therapy needs. You presented functioning below your baseline following two recent
hospitalizations. You have been making progress with therapy. It has not yet been shown that you have reached
a plateau in function. Therefore, continued services are 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 SNF services have been met. The Plan must continue coverage for the SNF
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued
skilled nursing facility (SNF) care.

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.