Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no clinical advantage of an LTACH over acute hospital.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for an MRI for the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is a network provider available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for an MRI for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a provisional splinting (D4321).

You asked the Plan to pre-approve the provisional splinting. You say that you cannot afford the cost of this service. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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. Therefore, we decided that the Plan does not have to pre-approve a provisional splinting (D4321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea (J0178) injections.

You asked the Plan to pre-approve Eylea. You say that the Eylea is medically necessary. The Plan denied your request. The Plan says a trial of bevacizumab is required before alternatives can be considered.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step 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 Eylea. Our reviewer says that Eylea is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drug, or any reason why the plan preferred drug would be unsafe or ineffective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea (J0178) injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2020.
You asked the Plan to pay for the dental service. You say that you did not know that a claim was filed. You say that you went to the office to check the damage made by the provider when she broke your tooth. You also say that you should not be responsible for the damage that the provider did. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan also says that you are not responsible for the duplicate charges.
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. The record shows that you are responsible for the claim amount of $70. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for continued care with an out-of-network endocrinologist.

You asked the Plan to pre-approve the referral. You say that this provider has paid careful and attentive care to your issues. The Plan denied your request. The Plan says management of osteoporosis and surveillance of the thyroid nodule can be performed in-network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found although there are no specific criteria given for seeing an out of network provides the provided, plan language does say it is justified in case of an emergency. It does not appear to me that this is an emergency nor is there anything unique to this case that would suggest the need to see this particular endocrinologist vs an in-network endocrinologist who should have access to the same proposed treatments for osteoporosis and the thyroid disease as has been proposed.

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for continued care with an out-of-network endocrinologist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery (22869).
You asked the Plan to pre-approve Vertiflex surgery. You say that there are several well-structured studies demonstrating the tremendous benefit of this procedure for the treatment of spinal stenosis. The Plan denied your request. The Plan says the proposed treatment is experimental or investigational.
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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully support the spinal decompression device procedure over the "gold standard" of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for the enrollee's medical condition. Contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. Superion indirect lumbar decompression using the Vertiflex device would not be considered the standard of care for the enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a free soft tissue graft (D4277) for tooth # 25.

You asked the Plan to pre-approve the dental service. You say that you had a consultation with a periodontist. You say that you were informed that if you did not have the graft procedure, you could lose some or most of your teeth. The Plan denied your request. The Plan says free soft tissue graft is not listed as a covered service. The Plan also says that any services not listed are not covered.

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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve a free soft tissue graft (D4277) for tooth # 25.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) provided August 31, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that your colonoscopy should be considered a screening colonoscopy with no cost-share to you. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that a diagnostic colonoscopy is performed in order to explain symptoms identified by your physician, because you've had a previous colonoscopy that resulted in the removal of polyps, or other colorectal related conditions. It further says that if your physician orders a diagnostic colonoscopy see "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" or "Outpatient diagnostic tests and therapeutic services and supplies" for cost-share. The Plan contract also says that you must pay a $325 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $325 copayment for the colonoscopy. In this case, the colonoscopy was performed due to a medical history of adenomatous polyps and is therefore considered diagnostic. The diagnostic colonoscopy falls within the Outpatient surgery 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 diagnostic colonoscopy (45378) provided August 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve sacroiliac joint injections.
You asked the Plan to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). You say that the enrollee needs sacroiliac joint injections for pain relief. The Plan denied your request. The Plan says the enrollee has not had any tests done for the pain in the low back.
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 injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no imaging or physical exam findings that support performing the SI joint injection. At this time, the request is deemed not medically reasonable or 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 injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096) have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the enrollee was independent for bed mobility. The enrollee required stand-by assistance for standing up, sitting down and walking to 120 feet times two using a two wheeled walker. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The enrollee's care needs can be met at a lower 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health admission.

You asked the Plan to pre-approve inpatient mental health admission. You say that this admission 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 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 inpatient psychiatric admission. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the records show a diagnosis of Major depressive disorder, recurrent. Your medical history is notable for multiple strokes. You were receiving inpatient psychiatric services. At that point you were noted to be stable. The notes state you are hoping to wait for discharge when an apartment you are moving to will be available. You are adamant that you want to live on your own. However, as of the dates in question, the documentation does not support that it is medically reasonable and necessary to continue psychiatric care at the acute inpatient level. Medicare for inpatient admission are no longer 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 inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a continuous passive motion device for shoulder surgery.
You asked the Plan to pre-approve continuous passive motion device. You say that you need this device. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because Medicare does not cover a continuous passive motion device for shoulder surgery.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve use of a continuous passive motion device for shoulder surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services from October 1, 2020, to October 18, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you were treated horribly at the facility. You say that the facility was a mess. You say that you feel the rehab did not resolve all of your issues. You also say that you feel you should not be responsible for the bill. The Plan denied your request. The Plan says there is a $0 copayment per day for days 1 to 20 and a $165 copayment per day for days 21 to 100. The Plan says that your stay was for a total of 25 days. The Plan also says that the claim was processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 copayment per day for days 1-20; $165 copayment per day for days 21-100 for skilled nursing facility (SNF) care. You have been asked to pay $0 copayment per day for days 1-20; $165 copayment per day for days 21-100 for the SNF services. the SNF services falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services from October 1, 2020, to October 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99211).

You asked the Plan to pay for the physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says the CPT code is not eligible for payment as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99211 is not supported in the medical record. Specifically, this CPT code is not recognized by the Medicare Outpatient Prospective Payment System. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99211).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility services provided September 22, 2020 to September 30, 2020.
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says that a corrected claim is required because there were no revenue codes included.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the documentation submitted by the provider shows that the claim was timely and did include the revenue codes. The plan has not provided documentation to support their denial. Therefore, we decided that the Plan has to pay for skilled nursing facility services provided September 22, 2020 to September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999) provided on October 26, 2020.
You asked the Plan to pay for the dental services. You say that you were never informed that there was a frequency limitation for a comprehensive oral evaluation. You say that you should not have to pay for this service because you were not provided this information. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that the unspecified preventive service is not listed as a covered service.
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 frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 28, 2020. Additionally, the unspecified preventive services is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999) provided on October 26, 2020.