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

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on September 13, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as you were informed there would be no charges beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $10 copayment for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay a $10 copayment for the office visit. The record indicates these services were performed in-network. 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 office visit (99214) provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed wedges.

You asked the Plan to pre-approve the wedges. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve bed wedges.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ambulance transportation services provided on April 28, 2021.  

You asked the Plan to pay for the ambulance transportation services. You say that these services were medically necessary for your emergency. The Plan denied your request. The Plan says that these services have been billed incorrectly.  

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. In this case, medical records are needed to determine the medical reasonableness of the provided services. There is no evidence that the Plan requested this information from the provider. Therefore, we decided that the Plan has to pay for the ambulance transportation services provided on April 28, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 7, 2021.

You asked the Plan to pay for the services provided. You say that there is no contractual agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis center.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 7, 2021.
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 improving and should only require short-term additional acute care services for monitoring of blood pressure and ostomy function 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.    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 prophylaxis - adult (D1110) provided August 9, 2021. 
 
You asked the Plan to pay for the dental cleaning. You say that it is cruel to deny a dental cleaning. The Plan denied your request. The Plan says you exceeded your dental maximum prior to this service so it is not covered. 
 
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. The Plan covers the dental cleaning up to the Plan's $200 annual dental allowance. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim was processed, you had used your full $200 dental allowance.  Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames provided on August 17, 2021.

You asked the Plan to pay for eyeglass frames. The Plan denied your request. The Plan says the claims record indicates you received one pair of eyeglass frames on November 4, 2020. This means you would not be eligible for another pair of frames until a year has elapsed from November 4, 2020.

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 these services every year.

We looked at the file and the Plan's rules. The file shows you received one pair of eyeglass frames on November 4, 2020. This means you would not be eligible for another pair of frames until a year has elapsed from November 4, 2020. Therefore, we decided that the Plan does not have to pay for eyeglass frames provided on August 17, 2021.
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 and should only require short-term additional 
acute care services in preparation for and following surgery 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. Completion of care at the current location is recommended prior to transfer to 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 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: 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 June 2, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the claims history indicates the enrollee was in an inpatient hospital status on this date of service. Ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is considered part of the inpatient admission, and not separately payable.

The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is
considered "patient transportation" and is covered as an inpatient hospital service.

We looked at the file and Medicare rules. In this case, the documentation has determined the enrollee was transported to another facility temporarily for care. This is not separately payable from the inpatient services according to Medicare rules. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hepatic function panel coded 80076 provided on April 12, 2021.  You asked the Plan to pay for the hepatic function panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 80076 for the hepatic function panel is a column II code to column I code 80053. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the hepatic function panel coded 80076 provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), bitewings - two radiographic images (D0272), and prophylaxis - adult (D1110) provided August 2, 2021, by an out-of-network (OON) provider.  

You asked the Plan to provide additional payment for the periodic oral exam, bitewing x-rays and dental cleaning. You say that you should have the same $0 copayment for in and out-of-network benefits. The Plan denied your request. The Plan says the cost-sharing was applied correctly. You are responsible for the difference between the Plan's allowed amount for the services and the total amount billed by the OON provider.  

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. The Plan contract says that if you choose to see an Out-of-Network dentist you might be billed for charges above what the Plan pays, even for services listed as $0 copayment.    

We looked at the file and Medicare rules. In this case you obtained dental services from an OON provider. The Plan provided documentation showing that they covered the full allowed amount for the services and you are only responsible for the difference between the Plan's allowed amount for the services and the total cost billed by the OON provider. Therefore, we decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), bitewings - two radiographic images (D0272), and prophylaxis - adult (D1110) provided August 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 21, 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 domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.  

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and is currently unstable for transfer to the LTACH.  

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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on August 24, 
2020, through August 31, 2020 and billed with Patient Driven Payment Model (PDPM) code GAXF1.

You asked the Plan to pay for the SNF services. You say that you would like reconsideration because all of the 
appropriate information was forwarded to the Plan and the documentation supports the billed PDPM code. The 
Plan denied your request. The Plan says that the documentation submitted is incomplete.

The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a 
prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment 
System (HIPPS) rate code. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have been met. Specifically, we received a copy of the Minimum Data Set for the 
Assessment Reference Date dated August 30, 2021. The documentation also indicates that this assessment was 
completed on September 26, 2021. The documentation submitted supports the claim as billed. Therefore, we 
decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on August 24, 2020, 
through August 31, 2020 and billed with Patient Driven Payment Model (PDPM) code GAXF1.

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya 100mg/ml subcutaneous syringe for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed.

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 or necessary. Our physician reviewer found based on the medical 
records provided the enrollee kyrizi, Cosentyx, Otezla or Enbrel. Based on the medical records provided there 
is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects 
for the enrollee.

We looked at this physician's review, the file, and Medicare rules. The enrollee must try and fail two of the 
plan's step therapy drugs. Only one of these drugs has been tried. 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 Ilumya 100mg/ml subcutaneous syringe for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided there is no documentation that you are insulin treated with three or more daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump.

The records document once daily insulin use. There is no documentation that your insulin treatment regimen requires frequent adjustment based on testing results. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient clinic visit provided on July 27, 2021.  

You asked the Plan to pay for an outpatient clinic visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  

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 did not pre-approve the services at issue. 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 an outpatient clinic visit provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens, polycarbonate (V2784) provided on August 31, 2021.

You asked the Plan to pay for lens, polycarbonate. The Plan denied your request. The Plan says lenses made of 
polycarbonate or other impact-resistant materials are generally considered medically necessary for patients 
with functional vision in only one eye. 

Polycarbonate lenses for indications such as light weight or thinness is generally not established as medically 
necessary. In this case, no clinical records are provided for review to establish the patient as functionally 
monocular or having a particularly high refractive correction.

Medicare rules say use of polycarbonate or similar material (V2784) or high index glass or plastic 
(V2782, V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature.

We looked at the file and the Medicare rules. Medicare says use of polycarbonate for indications such as light 
weight or thinness will be denied as a noncovered deluxe feature. Therefore, we decided that the Plan does not 
have to pay for lens, polycarbonate (V2784) provided on August 31, 2021.