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

We decided that the Plan does not have to waive the copayment forpodiatry service provided on July 22, 2020.You asked the Plan to waive the copayment forpodiatry visit. You say that your Plan policy clearly states that all out-of-pocket costs are waived.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $50 copayment for podiatry visit. You have been asked to pay the allowed amount of $43.73, which is less than the $50 copayment for podiatry visit. Podiatry visit falls within the Podiatry Services 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 forpodiatry service provided on July 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status currently does not require intensive physician and nursing supervision in an IRF. While the enrollee may benefit from additional physical and occupational therapy the documentation does not support that he requires this therapy on an IRF level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe venipuncture services provided on August 6, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forOON venipuncture services. You say that the enrollee said Medicare was his primary insurance.The Plan denied your request. The Plan says this service was 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 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 Plan does not have to pay forthe venipuncture services provided on August 6, 2020, by an out-of-network (OON) provider.
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 enrollee needs acute rehab. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 medically necessary. Our physician reviewer found you were admitted for altered
mental status associated with a transient ischemic attack. Your medical needs are now stable. You have no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program. There is not a reasonable expectation that you 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided on March 13, 2020.You asked the Plan to pay forthe ambulance service. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Original Medicare is responsible for this claim.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospicepays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe ambulance service provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you confirmed with this doctor's office that they were in-network.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan says that this out-of-network doctor's office may have given you incorrect information because they were not a Plan provider on the date of service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has 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 forthe medical services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc injection services.You asked the Plan to pre-approvethe Orthovisc injection services. You say that you cannot sleep and your knee swells up. You say that you have tried different pain medications and rubs without success. You say that you are on other blood thinners and are unable to take other medications.The Plan denied your request. The Plan says they do not see records that show the enrollee had a poor response to one of the preferred drugs.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implementstep therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Orthovisc injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has osteoarthritis of her left knee and is allergic to NSAIDs. The enrollee had intra-articular steroid injection services, but the duration of pain relief was only 3-4 weeks. The enrollee should be able to take one of the first step medications. There is no documented contra-indication to these first step medications 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 Orthovisc injection services have not been met.Therefore, we decided that the Plan does not have to pre-approveOrthovisc injection services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided on June 19, 2020.You asked the Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided on June 19, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the documentation provided supports the need for SNF care.The Plan denied your request. The Plan says the SNF care being requested is not medically necessary. The Plan says that the enrollee's needs can be provided in an alternative levelof 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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound care or other ongoing SNF level skilled nursing need. The enrollee appears afebrile, without need for oxygen or breathing treatments, notes reveal occasional cough but no more than baseline. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 30, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you did not go to the clinic you were assigned to because your doctor doesn't work there.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 forthe medical services provided on June 30, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided from May 18, 2020, to June 6, 2020.You asked the Plan to pay forthe SNF services. You say that this patient required skilled care and these services should be covered.The Plandenied your request. The Plan says he patient required no nursing services that would be considered skilled under Medicare rules.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed aboveare 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the patient received oral medications and had stable vital signs.

Regarding rehabilitation services, the patient received physical therapy in the SNF.However, by the dates of service at issue, the patient was at a contact guard assist level with functional mobility including gait to 125 feet with a rolling walker. Our physician reviewer also said that this patient had no identifiable skilled nursing service needs on the dates of service in question and the patient did 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided from May 18, 2020, to June 6, 2020.Please note that the Plan already approved SNF care from May 8, 2020, to May 17, 2020, so those dates of service are not addressed by this decision.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan Hycela(J9311).

You asked the Plan to pre-approve Rituxan Hycela. You say that this service is medically necessary.The Plan denied your request. The Plan says that the service requested for the enrollee does not meet medically reasonable or necessary standards.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Rituxan Hycela. Our reviewer says that Rituxan Hycela is medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Rituxan Hycela is supported in the National Comprehensive Cancer Network (NCCN) compendium for the enrollee's condition. The documentation supports that the requested use is safe and effective in this caseWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan Hycela have been met.Therefore, we decided that the Plan has to pre-approveRituxan Hycela (J9311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status currently does not require intensive physician and nursing supervision in an IRF. While the enrollee may benefit from additional physical and occupational therapy the documentation does not support that he requires or can fully tolerate this therapy on an IRF level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided.

You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says rules for SNF care have not been met.

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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary did not require skilled nursing or therapy services on a daily basis and did 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 the SNF care have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion Interspinous Spacer.You asked the Plan to pre-approvethe Superion Interspinous Spacer. You say that the records provided support the medical necessity of the service in dispute.The Plan denied your request. The Plan says the current medical literature indicates that the requested service is considered experimental and investigational, as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized pee-reviewed medical literature.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 the Superion Interspinous Spacer. Our reviewer says that a Superion Interspinous Spacer is not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure anddevice is considered experimental and investigational.  There is a need for further evaluation of efficacy and re-operation rate as well as a clinical practice guideline to determine its utility.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 Superion Interspinous Spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion Interspinous Spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (C9753, C9752, 22899).

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met..

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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for the treatment of degenerative low back pain. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (C9753, C9752, 22899).