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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 1,
2021, to May 7, 2021.
You asked the Plan to pay for the SNF care provided from May 5, 2021, to May 7, 2021. You say that you
were not physically ready to be discharged home. You say that you received a bill for the stay. You say that
you are on able to pay it. You also say that you are on a fixed income. The Plan denied your request. The Plan
says you did not require daily skilled services.
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 pay for the SNF care from May 5, 2021, to May 7,
2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician
reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and
judgment of a skilled professional nurse. You did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. You did 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. Based on this information, we decided that
Medicare rules for coverage of the SNF care from May 5, 2021, to May 7, 2021, have not been met.
Specifically, the file shows that you were no longer receiving daily skilled services on the dates of service in
this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care
provided from May 1, 2021, to May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON radiation therapy services. You say that you received substandard from the participating provider who previously treated you. The Plan denied your request. The Plan says there are multiple in network providers who can supply radiation therapy and who are not a part of the previous facility you used.
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 radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on May 25, 2021.
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says all hearing aids and hearing services be obtained from Plan providers.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only obtained from Plan providers.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Eylea injections (J0178) provided December 23, 2020.

You asked the Plan to waive the coinsurance for the Eylea injections. You say that you believe you were never informed about the out-of-pocket costs. The Plan denied your request. The Plan says the cost share has processed correctly for these services.

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 20% coinsurance for Medicare Part B Prescription Drugs. 

You have been asked to pay a total cost share of $742.60 for the Eylea injections. The 20% coinsurance for the drug injections would be $750.75 ($3753.76 Medicare-allowed amount x 20% coinsurance). Therefore, you have been charged less than the requested coinsurance. The Eylea injections 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 Eylea injections (J0178) provided December 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided on January 6, 2021 and January 7, 2021.
You asked the Plan to pay for home infusion services. You say that these services were provided to the enrollee in good faith so that the enrollee would recover successfully. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these codes are not valid for Medicare purposes and are not payable.
The Plan must follow Medicare rules. Medicare rules say that codes 99601 and 99602 are not valid for Medicare purposes and are not payable.
We looked at the file and Medicare rules. These codes are not valid for Medicare purposes and are not payable. Based on this information, we decided that Medicare rules for coverage of home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services provided on January 6, 2021 and January 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at
24-hour facility (99053) provided on March 26, 2021.

You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based
on the medical records. The Plan denied your request. The Plan says no separate payment is available for this
claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status code
"B" for Bundled Code under the Physician Fee Schedule. For these cases, payment for covered services is
always bundled into payment for other services not specified. Based on this information, we decided that
Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan
does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility (99053)
provided on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from June 11, 2021, to June 14, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that it was the hospital's decision to admit you because it was medically necessary. The Plan denied your request. The Plan says you have been asked to pay 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 a $450 copayment per day, days 1 to 4 for inpatient care at an in-network inpatient hospital.
You have been asked to pay a $450 copayment for each day the inpatient hospital admission. ($450 x 3 days = $1,350). The inpatient hospital admission falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from June 11, 2021, to June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on January 31, 2021.

You asked the Plan to pay for the transportation services. You say that the enrollee requires assistance moving and was in need of constant supervision. You say that the enrollee has a history of falls that have resulted in a fracture and large hematoma. You also say that the services were medically necessary. The Plan denied your request. The Plan says the transportation services were 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 the transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this enrollee on January 31, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on January 31, 2021. The reviewer also found that the documentation does not support that the ambulance transport on January 31, 2021, was medically reasonable and necessary for the enrollee.

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 transportation services have not been met. Specifically, the file does not support that other means of transport were contraindicated Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided on January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 24, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that it is not feasible to have a prior history because this is your first dental visit since becoming insured when you enrolled in Medicare in 2020. You also say that you believe you are entitled to a full reimbursement up to the limit of your coverage. The Plan denied your request. The Plan says there is no history of periodontal scaling or periodontal surgery. The Plan also says that your provider stated that scaling and root planing has been recommended for a long time, but you have never undergone treatment.
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, periodontal maintenance (D4910) is only covered with a history of scaling and root planing (deep cleaning) or periodontal surgery. Therefore, we
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires extended and acute-care
level interventions provided by complex care trained staff, interdisciplinary treatment and teams driven
rehabilitation to resume reconditioning and improvement. The Plan denied your request. The Plan says the
enrollee is receiving appropriate in-patient acute care and does not require transfer to an 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 that 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 review indicates that 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (96401) provided April 12, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 96401 is not supported in the medical record. Specifically, there is a more appropriate CPT code to describe the services at issue. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (96401) provided April 12, 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 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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown (D6740) for tooth #4 or pay more for the retainer crown (D6740) for tooth #6 provided on April 7, 2021.
You asked the Plan to pay for the retainer crown for tooth #4 and to pay more for the retainer crown for tooth #6. You say that the Plan's website does not show that meeting the $1,000 maximum benefit stops someone from receiving the 50% discount for services. You also say that you would like your share adjusted so you are only responsible for a 50% coinsurance for each service. The Plan denied your request. The Plan says you have reached your dental plan's calendar year maximum of $1,000.
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 pays up to the Calendar Year Maximum of $1,000. The record shows that you met the annual maximum benefit while processing this claim for the April 7, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6740) for tooth #4 or pay more for the retainer crown (D6740) for tooth #6 provided on April 7, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Prolia.

You asked the Plan to pre-approve Prolia. You say that you have tried Fosamax in the past but it did not work for you. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of one intravenous bisphosphonate therapy (such as zoledronic acid) before they will approve Prolia.

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. 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. 

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 did not submit medical records for review in this case. We requested medical records, but they were not provided to us. Without medical records, we cannot determine whether you meet the criteria for a step therapy exception for use of Prolia.

The Plan says that you have not tried an intravenous bisphosphonate (such as zoledronic acid), but without records it cannot be determined if this drug would likely be less effective and/or have adverse effects for you. Therefore, the Plan has not shown that its decision to deny Prolia is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-approve use of Prolia.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the computed tomography (CT) guided
radiation you received on March 18, 2021, and March 19, 2021.
You asked the Plan to reduce the copayments for the radiation therapy services. You say that you think the
percentage of the charge paid by the Plan versus your cost sharing is unfair. The Plan denied your request. The
Plan says you were charged these copayments 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 a $60
copayment for each radiation therapy service.
You have been asked to pay a $60 copayment for each of the radiation therapy services. 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 reduce the copayments for the computed tomography (CT) guided radiation you received on
March 18, 2021, and March 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare criteria for
LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute
care and does not require transfer to an 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 that 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 review indicates
that the enrollee does not require services at the LTACH that are not available at the acute care hospital where
he 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 LTACH services.