Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay forepoetin alfa (J0885) provided on April 2, 2020, through April 30, 2020.You asked the Plan to pay forepoetin alfa. You say that the service rendered was medically necessary.The Plan denied your request. The Plan says that the services rendered were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked ourphysician 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 epoetin alfa. Our reviewer says that the service is medically necessary. Our physician reviewer found epoetin alfaisindicated for the management/treatment of aplastic anemia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epoetin alfa have been met.Therefore, we decided that the Plan has to pay forepoetin alfa (J0885) provided on April 2, 2020, through April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections provided by a participating provider on June 18, 2020.You asked the Plan to waive the copayment for injections. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay less than a 20% coinsurance of the allowed amount for injections. The total allowed amount is $12,321.10. Your 20% coinsurance amount is $2,464.22 ($12,321.10 x 20% = $2,464.22). You are being asked to pay the lesser amount of $1,635.17. Injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to paythe 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 injections provided by a participating provider on June 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible and coinsurance for an eye exam (92014) and ophthalmic diagnostic imaging (92134) performed on November 13, 2019.
You asked the Plan to waive the deductible and coinsurance for an eye exam and ophthalmic diagnostic imaging. You say that the provider told you that you owe $0. The Plan denied your request. The Plan says that the correct cost-sharing was applied.
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 after the deductible for each Medicare-covered vision exam. The case record shows that you are being charged $36.80, or 20% coinsurance of the Plan-allowed amount of $184.04, for an eye exam and ophthalmic diagnostic imaging. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment after the deductible for an eye exam and ophthalmic diagnostic imaging. The case record does not support that a deductible applies to the services performed on November 13, 2019. Therefore, we decided that the Plan has to waive the deductible and coinsurance for an eye exam (92014) and ophthalmic diagnostic imaging (92134) performed on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient lives in an assisted living facility where she is receiving physical therapy for sequelae of a stroke in March 2020. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgeries provided on July 6, 2020, and July 13, 2020.
You asked the Plan to waive the copayment for cataract surgeries. You say that you would like the copay waiver to apply because you are struggling financially. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a cataract surgery on July 6, 2020. Therefore, you are responsible to pay the $300 copayment. You received a cataract surgery on July 13, 2020. Therefore, you are responsible to pay the $300 copayment. The total amount you owe is: $600. You have been asked to pay the total copayment amount of $600 for cataract surgeries. Cataract surgeries fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgeries provided on July 6, 2020, and July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Phenylephrine/Ketorolac ophthalmic solution (J1097) provided on February 4, 2020.You asked the Plan to waive the coinsurance forthe Phenylephrine/Ketorolac ophthalmic solution. You say that the provider mistakenly billed the wrong amount.The Plan denied your request. The Plan says the coinsurance applied correctly in this case.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $87.76 for the Phenylephrine/Ketorolac ophthalmic solution ($438.80 allowed amount x 20% coinsurance = $87.76). the Phenylephrine/Ketorolac ophthalmic solution falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe Phenylephrine/Ketorolac ophthalmic solution (J1097) provided on February 4, 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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at an alternate level of 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided from January 21, 2020, to February 24, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you were not informed that you would owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services provided from January 21, 2020, to February 24, 2020 for a total of 6 visits. Therefore, you are responsible to pay a $35 copayment per each service. The total amount you owe is: $35 (copayment) x 6 (PT visits) = $210. You have been asked to pay the total copayment amount of $210 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 for outpatient rehabilitation services provided from January 21, 2020, to February 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi.
You asked the Plan to pre-approve Aloxi. You say that the enrollee needs this medication to get chemotherapy.
The Plan denied your request. The Plan says the enrollee does not meet the medically-accepted standard(s) for
coverage of this drug.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
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 Aloxi. Our reviewer says that Aloxi is
not medically reasonable and necessary for the enrollee. Our physician reviewer found Aloxi is not Food and
Drug Administration (FDA) approved for use with minimal risk chemotherapy agents. Our reviewer found that
Aloxi is not supported in any of the CMS approved compendia for the requested use. Our physician reviewer
also found that the use of Aloxi is not listed as not indicated, not supported, or not recommended for this use.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aloxi have not been met. Therefore, we decided that the Plan does not have to
pre-approve Aloxi.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 18, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration because the member was not present to obtain prior authorization.The Plan denied your request. The Plan says it is the provider's responsibility to verify the member's eligibility, health benefits and obtain prior authorization before rendering services.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 medical services provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe SNF care provided from March 12, 2020, to April 2, 2020.You asked the Plan to pay forthe SNF care. The Plan denied your request. The Plan says the SNF care was not reasonable and necessary under Medicare guidelines.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 you did not meet the Medicare criteria for SNF care. Our physician reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment ofa skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met.Therefore, we decided that the Plan does not have to pay forthe SNF care provided from March 12, 2020, to April 2, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing system.
You asked the Plan to pre-approve a standing system. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says a standing system is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a standing system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for infection of right foot treated with surgery and antibiotics. Medical problems are stable. There are
no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation
needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy
program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 17, 2020.You asked the Plan to pay for the psychotherapy services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plandid not pre-approve the psychotherapy services. 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 forpsychotherapy services provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 11,
2020 to March 14, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the hospital nevertheless maintains
that the decision to admit the enrollee to the hospital for further management of severe mitral stenosis was
warranted and medically necessary. The Plan denied your request. The Plan says the requested coverage for
inpatient admission has not been approved as it does not meet medical necessity.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee was admitted post RHC to undergo MVR/TVR, Maze procedure, left atrial appendage clip and possible aortic root repair. EP team was consulted for perioperative rhythm management.
Surgery was planned for 3/13. The enrollee was deemed ASA Risk 3 for the procedure under general
anesthesia. On re-evaluation of benefit to risk criteria, decision was made to cancel surgery and continue with
medical management. He was discharged home on 3/14/2020. The review has determined that the record
showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's
necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
does not have to pay for the acute inpatient hospital care provided from March 11, 2020 to March 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 12, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on May 12, 2020.