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

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

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 had network providers
available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the requested bed. The Plan denied your request. The Plan says the requested service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that this radiation therapy is reasonable to prevent a symptomatic response. The Plan denied your request. The Plan says the denial of authorization for this SBRT is correct, because research does not show that the enrollee's type of cancer responds better to this than to another treatment plan such as complex isodose treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for metastatic disease, SBRT is generally only indicated for patients with oligometastatic disease. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the enrollee's performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks. For this enrollee, there are other sites of widespread metastases that would not be targetable by SBRT. For this enrollee, the intent is palliative and does not seem to meet the ASTRO model policy or generic indications for SBRT being able to encompass all sites of disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
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. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet the requirements.

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 the enrollee has a history of hypertension, diabetes, and renal cancer, and was admitted to the acute care hospital with a hemorrhagic stroke. The enrollee required intubation. A tracheostomy and a PEG tube have been placed. The enrollee opened her eyes but was making no communication attempt. LTACH's are certified as acute care hospitals, and in general, LTACH's do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen supplies.

You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you cannot afford these
charges. 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 20%
coinsurance for durable medical equipment.

You have been asked to pay 20% coinsurance for the oxygen supplies. The oxygen supplies fall within the
durable medical equipment 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 oxygen
supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and care.
You asked the Plan to pre-approve SNF care. You say that the enrollee's acute and chronic medical conditions require daily medical oversight by a physician. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested services are 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 of this letter 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 that there are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission and care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient behavioral health visits you had from July 1, 2020, to September 20, 2020.
You asked the Plan to waive the copayments for the behavioral health visits. You say that this provider is in-network, so your copayment should only be $5 per visit. The Plan denied your request. The Plan says you were charged this copayment correctly and you were not assessed the out-of-network cost sharing amounts.
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 $30 copayment per visit for in-network outpatient mental health care. You have been asked to pay a $30 copayment per visit for the behavioral health visits. The behavioral health visits fall within the in-network outpatient mental health 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 copayments for outpatient behavioral health visits you had from July 1, 2020, to September 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS Heart Failure (HF) System.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have chronic
combined congestive heart failure, coronary artery disease, and irregular heartbeat (atrial fibrillation). The
requested CardioMEMS HF System is considered experimental in nature, as the effectiveness is uncertain. The
services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a CardioMEMS Heart Failure (HF) System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spravato sol kits.
You asked the Plan to pre-approve self-administered drug. You say that you have not received benefits from other medications. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve spravato sol kits.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injections (62323).

You asked the Plan to pre-approve the epidural steroid injections. You say that the repeat injection is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that repeated epidural steroid injections are covered when the last injection provided pain relief or improved function. 

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 epidural steroid injections. Our reviewer says that the injections are medically necessary. Our physician reviewer found the records provided support that the previous injection provided more than 80% pain relief. Coverage criteria is met. 

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 epidural steroid injections have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injections (62323).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (92015) provided by an out of network (OON) provider.

You asked the Plan to pay for the refraction services. You say that you feel that you were misled by the provider and the plan since it says in the plan book that you are covered for a refraction. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the refraction services (92015) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (R0075 and Q0092) provided on October 13, 2020.
You asked the Plan to pay for the transportation and set up of a portable x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare rule for payment of this claim has not been met.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of a portable x-ray have not been met. Specifically, this claim has been billed with place of service code 31, indicating that the member was in a Part A SNF stay. These services are not separately billable to Medicare Part B when the member is in a part A SNF stay. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (R0075 and Q0092) provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided by an OON provider.

You asked the Plan to pay for the office visit. You say that you ask that your claims to be reconsidered as you
do have a referral from PCP. The Plan denied your request. The Plan says non-emergent services with noncontracted
providers require prior authorization before services being rendered. Referrals must be received
from the chosen primary care physician. The referral was from the physician assistant.

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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder orthosis (L3670) provided on January 16, 2020, by an OON provider.
You asked the Plan to pay for a shoulder orthosis. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met because the requested item was not received from a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a shoulder orthosis (L3670) provided on January 16, 2020, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avapro for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Avapro for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam.

You asked the Plan to waive the copayment for the eye exam. You say that this copayment is a financial hardship for you. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for Medicare-covered eye exams.

You have been asked to pay a $40 copayment for the eye exam. 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 comprehensive eye exam.
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 all disciplines agree that IRF is the most appropriate
level of care. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
record supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from September 10, 2020, to September 17, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you would like the Plan to pay this bill in full. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment per day for days 1-7 for inpatient hospital care. You have been asked to pay a $200 copayment per day for days 1-7 for the inpatient hospital services. You were in the hospital for 7 days, so the total copayment obligation is $1400 (7 x $200 = $1400). 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 services you received from September 10, 2020, to September 17, 2020.