Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation provided on March 31, 2021.

You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied your request. The Plan says you must use a provider in the Plan's vision care network.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the ophthalmological services, medical examination and evaluation were not provided by a provider in the Plan's Vision Care network. Based on this information, we decided that the Plan's rules for coverage of ophthalmological services, medical examination and evaluation have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation provided on March 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided on July 12, 2021.
You asked the Plan to pay for inpatient hospital care. 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and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 10, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on September 27, 2021.
You asked the Plan to pay for the injection of a therapeutic or diagnostic substance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not submit any medical records to validate the medical necessity of this service.
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 62320 is not supported in the record. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the injection of a therapeutic or diagnostic substance have not been met. Therefore, we decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on September 27, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for tumor immunohistochemistry testing (88361) provided on May 7, 2021.  You asked the Plan to pay for tumor immunohistochemistry testing. You say that the enrollee's treating physician ordered this testing after making a professional determination of medical necessity. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because code 88361 is not covered for diagnosis code K22.70.  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 rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.  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 specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this test code would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Furthermore, the Plan has based their denial on the billing and coding rules established in Local Coverage Article (LCA) Billing and Coding: Lab Special Histochemical Stains and Immunohistochemical Stains (A57611); however, this LCA does not have jurisdiction in the geographic area where the laboratory testing was performed. Therefore, these billing and coding rules do not apply to this claim. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for tumor immunohistochemistry testing (88361) provided on May 7, 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: 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 somewhat unstable but without complex care needs and requires only short-term additional acute care services including weaning trials that can be administered safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.
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: 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 somewhat unstable but without long-term complex care needs and requires only short-term additional acute care services that can be administered safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.

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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Ultrasound (76770) provided on September 3, 2021.  You asked the Plan to pay for code 76770. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered a 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. In this case, we have confirmed that code 76770 is a column II code to column I code 93976. 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 Ultrasound (76770) provided on September 3, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that it is felt that SNF admission would be the best option for the enrollee. The Plan denied your request. The Plan says that there is no need for daily skilled services in the SNF setting.
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 the documentation supports that daily skilled services are needed and that SNF care is reasonable and necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. However, the enrollee does have documented daily skilled therapy needs. The enrollee is functioning below her baseline and has not yet been shown to have reached a new plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care 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 admission to a skilled nursing facility (SNF).
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing care.
You asked the Plan to pre-approve home health care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for home health care is correct, because there is no documentation of a change in treatment plan.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that the enrollee does not meet the Medicare criteria for home health care. Our physician reviewer found the enrollee does not have documented, ongoing skilled nursing needs. As such, home health skilled care visits are not medically 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from August 7, 2021, through September 5, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services was not medically necessary.
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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required (or received) skilled nursing services. This enrollee did not require (or receive) skilled therapy services. Daily skilled services were not required (or provided). This enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from August 7, 2021, through
September 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 8, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you saw the provider the day before and you feel that you should not be charged for the second visit for the same issue. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each visit or consultation with a specialist.

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office 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 office visit provided on July 8, 2021.
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 member is not functioning correctly and should continue physical therapy. The Plan denied your request. The Plan says the enrollee does not meet CMS guidelines for authorization and therefore SNF care is considered not medically necessary.

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 the enrollee no longer qualifies for SNF coverage. Our physician reviewer found that the enrollee does not have documented skilled nursing needs or skilled therapy needs. 

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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on September 25, 2021.  You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says the hearing aid benefit is provided by the Plan's hearing network provider.  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.   We looked at the file and the Plan's rules. The file shows that the hearing aids were no provided by the Plan's hearing network 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 September 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for flat feet.

You asked the Plan to pre-approve foot orthotics. You say that orthotics are medically necessary for treatment of flat feet. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for flat feet.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine venipuncture (36415), the laboratory services  (80048, 80076, 85025), and the chemotherapy administration (96413) rendered by the out-of-network (OON) provider on August 5, 2021 and August 19, 2021.    You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 at issue in this case is not a network provider with the Plan. 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 routine venipuncture, the laboratory services, and the chemotherapy administration. Our reviewer says that the services provided by the out-of-network provider were not medically necessary. Our physician reviewer found that the lock-in provision requires that the insured party receive all health care services from providers who participate in the plan. The treatment of Paroxysmal Nocturnal Hemoglobinuria (PNH) with Eculizumab is a standard of care but in-network providers should be able to provide this care. The out-of-network services were not reasonable or medically 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 the routine venipuncture, the laboratory services, and the chemotherapy administration have not been met.   The Plan has network providers available who can provide the services at issue in this appeal. 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 the routine venipuncture (36415), the laboratory services (80048, 80076, 85025), and the chemotherapy administration (96413) rendered by the out-of-network (OON) provider on August 5, 2021 and August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a pembrolizumab injection 1mg (J9271) provided on September 10, 2021.

You asked the Plan to waive the coinsurance for the pembrolizumab injection 1mg. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 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 20%z coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20%z coinsurance for a pembrolizumab injection ($18,824.45 x 20% = $3,190). Pembrolizumab injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a pembrolizumab injection 1mg (J9271) provided on September 10, 2021.