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

We decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).You asked the Plan to pre-approveSNF admission. You saythat SNF admission would benefit the enrollee due to weakness and multiple hospital stays.The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while the enrollee does have skilled nursing and skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgmentof a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvision services received from Zennioptical.com on August 5, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysyour vision benefits do not offer reimbursement for the use of an out-of-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 has network providers available who can provide 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 Plandoes not haveto pay forvision services received from Zennioptical.com on August 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.The Plan must follow Medicare rules. The rules say thatMedicare pays for care in a SNF when the four factors listed above 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/4/20 with L1 compression fracture and back pain status post a mechanical fall on 1/31/20. She underwent L1 bilateral percutaneous transpedicular vertebral augmentation-kyphoplasty with Kyphon cement and biplanar fluoroscopy. Based on review of the medical records provided, the requested admission to a SNF does not meet criteria. The enrollee does not require daily therapy and/or daily skilled nursing services. There is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6531.You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are medically necessary as you have issues with blood flow and discoloration in your leg. The Plan denied your request. The Plan says there is no supporting documentation indicating the Gradient Compression Stockings are being used for the treatment of an open venous ulcer.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services received on August 27, 2019.
You asked the Plan to pay for the services. You say that you have already paid over the maximum out-of-pocket amount of $5,900. The Plan denied your request. The Plan says the claims were processed appropriately.
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 that there is a $10,000 out-of-pocket maximum for both in and out-of-network services. The total for your in-network claims is $1,031.95 and the total for your out-of-network claims is $5,680.91. The combined amount of $6,712.86 is below the combined out-of-pocket maximum of $10,000. 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 pay for services received on August 27, 2019.
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 services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care setting. 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 long term acute care hospital (LTACH) services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services. You do not require these skilled nursing or skilled therapy services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician'sreview, 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-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forthe office visit provided on September 19, 2019.You asked the Plan to waive the copayment forthe office visit. You say that this was a primary care visit. You say that you should not have a copayment.The Plan denied your request. The Plansays that the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for each primary care doctor office visit for Medicare-covered services.The Plan says you must pay a $30 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the office visit. The medical records show that you were seen at a primary care office.Therefore, we decided that the Plan has to waive the copayment forthe office visit provided on September 19, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forchiropractic manipulative treatment provided from May 15, 2019 through November 5, 2019.You asked the Plan to waive the deductible forchiropractic manipulative treatment. You say that you are being charged out-of-network.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your out-of-network (POS) deductible is $1,000. This is the amount you have to pay out-of-pocket before we willpay our share for your covered out-of-network (POS) medical services. Chiropractic services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Chiropractic services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000out-of-network (POS) deductible applies to chiropractic services. This cost sharing is a contractual obligation that had not been met at the time chiropractic manipulative treatmentwas received fromMay 15, 2019 throughNovember 5, 2019.Therefore, we decided that the Plan does not have to waive the deductible forchiropractic manipulative treatment provided from May 15, 2019 through November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe Guardant360 test provided to the enrollee on July 10, 2019.You asked the Planto pay forthe test. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation does not support the medical necessity of the testing.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 pay for the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the available documentation in the case file does not support that the Guardant360 testing was medically reasonable and necessary for the enrollee in this case. There are no clinical medical records for review.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 test have not been met.Therefore, we decided that the Plandoes not haveto pay forthe Guardant360 test provided to the enrollee on July 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transport services provided on May 31, 2019.
You asked the Plan to pay for the air ambulance transport services. You say that the air ambulance transport services provided were medically necessary. The Plan denied your request. The Plan says the air ambulance transport services provided were not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance transport services. Our reviewer says that the air ambulance transport services provided were not medically necessary. Our physician reviewer found the enrollee was with a closed right hip fracture after a mechanical fall. There were no other injuries. Vital signs were stable. The right leg was neurovascularly intact. The sending facility did not have orthopedic surgical services and therefore was transferring the enrollee for definitive treatment at the receiving facility. The air ambulance services were not of an emergent nature. The enrollee was clinically stable and could have been safely transferred by ground ambulance for non-emergent surgical treatment of her hip fracture.
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 air ambulance transport services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transport services provided on May 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinpatient detoxification treatment for the enrollee.You asked the Planto pre-approvethetreatment. You say that this is medically necessary due to the enrollee's suicidal thoughts.The Plandenied your request. The Plansaysthe enrollee can be treated at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 
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 treatment. Our reviewer says that the requested treatment is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 10, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant. His vitals were normal and he was not showing any withdrawal symptoms.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 treatment have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinpatient detoxification treatment for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 9, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe laboratory services rendered to you on August 19, 2019.You asked the Plan to waive the deductible forthese services. You say that the services should have no cost share.The Plan denied your request. The Plan says the deductible was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $300 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the laboratory tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services was received on August 19, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe laboratory services rendered to you on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesupplies related to a non-therapeutic Medtronic continuous glucose monitor (A9276).You asked the Plan to pre-approvesupplies related to a non-therapeutic Medtronic continuous glucose monitor (A9276). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Medicare only covers a CGM if it has been FDA approved as being a therapeutic CGM. The Plan states the requested CGM has not been FDA approved as being a therapeutic CGM.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The file shows the requestedCGM supplies (A9276) are for a model CGM that is not FDA approved as being a therapeutic CGM. Based on this information, we decided that Medicare rules for coverage of supplies related to a non-therapeutic Medtronic continuous glucose monitor (A9276) havenot been met.Therefore, we decided that the Plan does not have to pre-approvesupplies related to a non-therapeutic Medtronic continuous glucose monitor (A9276).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found in the case of this enrollee, although ongoing acute care is required (BiPAP, IV antibiotics), there was insufficient evidence found in the provided records for requiring transfer to LTACH. The records show ongoing incomplete resolution of sepsis and atrial fibrillation, notes state currently "unstable." The enrollee does not require services that are not already available and covered at the current acute care facility and being administered safely and effectively. Therefore, this request for LTACH transfer will be considered not medically necessary 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-approvelong term acute care hospital (LTACH) services.
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-approveSNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of SNF care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewerto 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 records do not indicate that there are nursing issues that could not be addressed at a lower level of care. Criteria for coverage of SNF care are not met.Welooked 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-approveskilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNuedexta capsules.You asked the Plan to pre-approveNuedexta capsules. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Nuedexta capsules are not covered under the enrollee's Medicare Part B benefit.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-approveNuedexta capsules.Benefits for Nuedexta capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.