Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient physical therapy services provided from January 9, 2020 to February 5, 2020.
You asked the Plan to waive the copayment for the outpatient physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient physical therapy services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient physical therapy services from January 9, 2020 to February 5, 2020. You have been asked to pay a $30 copayment for each visit. The outpatient physical therapy 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 the outpatient physical therapy services provided from January 9, 2020 to February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 6, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on June 6, 2019.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 medical records show you are generally medically stable and the documentation does not support that you have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient PMR physician three times per week. The documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Medicare coverage criteria are not 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 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 provided on May 23, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 23, 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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 based on the documentation provided, you are currently undergoing treatment at an
acute care hospital (ACH) for a UTI with bacteremia. The enrollee is not intubated/ventilated. There is no
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required. Medicare coverage criteria are
not 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says the
coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that for coverage consideration of a power wheelchair, the
above criteria must be met.
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 a power wheelchair. Our reviewer says
that the requested power wheelchair is not medically reasonable and necessary. Our physician reviewer found
that the documentation in the case file does not support that the enrollee does not have sufficient upper
extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs
during a typical day. There is no documentation of limitations of strength, endurance, range of motion, or
coordination, presence of pain, or deformity or absence of one or both upper extremities.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does
not have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional five skilled nursing (SN) visits, two
additional home health aide (HHA) visits, and four additional social work visits to be provided in the home
health setting.
You asked the Plan to pre-approve the additional requested home health services. You say that the enrollee has
required daily wound care since being discharged from the hospital and continues to require this. This must
continue until the enrollee can be seen in the wound care clinic for evaluation for a wound vac. The Plan denied
your request. The Plan says the plan has approved the home health services provided but no further home
health care is necessary and cannot be approved.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional requested home health
services. Our reviewer says that the documentation does not support that necessity of the requested home health
services. Our physician reviewer found the enrollee is a 47-year-old man with a past medical history of morbid
obesity who suffered a closed fracture of the neck of left femur. A total arthroplasty of the hip was performed
on 6/4/20. The plan approved 17 skilled nursing visits, 4 PT visits, 4 home health aide visits, and 1 MSW visit.
The case file contains a skilled nursing note dated 7/8/20.
The documentation is insufficient to demonstrate that five additional SN visits, two additional HHA visits, and
four additional MSW visits are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's
condition and/or prevent deterioration. There is no clear treatment plan, nor documentation of response to
interventions thus far. Without clear documentation, it cannot be determined that any additional home health
services are reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the additional requested home health services have not been met. Therefore, we
decided that the Plan does not have to pre-approve an additional five skilled nursing (SN) visits, two additional
home health aide (HHA) visits, and four additional social work visits to be provided in the home health setting.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 12, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on January 1, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says non-emergency out of area services are 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 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 for the services provided to the enrollee on January 1, 2020.
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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
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 based on the documentation provided, you are currently undergoing treatment at a
skilled nursing facility following discharge from an acute care hospital. You have a tracheotomy and you are
on a ventilator. You are in need of long-term care but there is no evidence that you require an acute level of
care. Therefore, admission to an LTACH is not medically necessary or reasonable. 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 preapprove
long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), removal of torus mandibularis (D7473), bone replacement graft for ridge preservation - per site (D7953), adjust complete denture - maxillary (D5410), resin-based composite - two surfaces, anterior (D2331),resin-based composite - three surfaces, anterior (D2332) and resin-based composite - one surface, posterior (D2391) provided to the enrollee from February 13, 2020 through March 20, 2020 by multiple providers.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the enrollee was notified via the 2020 Annual Notice of Changes that the dental coverage was changing from a mandatory supplemental benefit to an optional supplemental benefit. The Plan states after being notified of this change, the enrollee did not contact the health plan to elect the optional supplemental dental benefit for 2020.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Since the enrollee did not elect the optional supplemental dental benefit for 2020, the enrollee does not have coverage under your benefit for non-Medicare covered dental comprehensive services. The services are not listed in the enrollee's EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), removal of torus mandibularis (D7473), bone replacement graft for ridge preservation - per
site (D7953), adjust complete denture - maxillary (D5410), resin-based composite - two surfaces, anterior (D2331),resin-based composite - three surfaces, anterior (D2332) and resin-based composite - one surface, posterior (D2391) provided to the enrollee from February 13, 2020 through March 20, 2020 by multiple providers.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzelex combination therapy with lenalidomide and dexamethaone. 
 
You asked the Plan to pre-approve Darzelex combination therapy with lenalidomide and dexamethaone. You say that the requested Darzelex combination therapy with lenalidomide and dexamethaone is medically necessary. The Plan denied your request. The Plan says the requested Darzelex combination therapy with lenalidomide and dexamethaone is not medically necessary. 
 
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 Darzelex combination therapy with lenalidomide and dexamethaone. Our reviewer says that the requested Darzelex combination therapy with lenalidomide and dexamethaone is not medically necessary. Our physician reviewer found this review relates to a request for Dazelex to be given with Dexamethasone and Lenalidomide will be added if tolerated for the enrollee with multiple myeloma in remission after previous chemotherapy. The drug is not FDA approved for use in patients in remission after previous chemotherapy. The CMS approved compendia do not support the requested use. This reviewer did not find any supporting citations in a PubMed search. The requested use is not listed as not indicated, not recommended or not supported in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darzelex combination therapy with lenalidomide and dexamethaone have not been met. Therefore, we decided that the Plan does not have to pre-approve Darzelex combination therapy with lenalidomide and dexamethaone.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98942) provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON chiropractic services. You say that this was medically necessary.The Plan denied your request. The Plan says this 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 for the chiropractic services (98942) provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee replacement (27447). 
 
You asked the Plan to pre-approve the knee replacement. You say that the knee replacement is medically necessary. The Plan denied your request. The Plan says 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 the knee replacement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of end-stage knee osteoarthritis or deformity. There is no documentation in the submitted medical records relative to physical therapy, exercise or weight loss attempts and failure. Comorbidities include spinal stenosis at the L4/5 level with radiculopathy for which treatment has not been exhausted. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of surgery prior to addressing the enrollee's lumbar radiculopathy and exhausting conservative treatment. 
 
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 knee replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee replacement (27447)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 13, 2019.You asked the Plan to payforthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plandoes not have to pay forthe laboratory services provided on November 13, 2019.