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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you require twenty-four hour care. The Plan denied your request. The Plan says that you have custodial care needs but custodial care is not covered.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that this is medically necessary. The Plan denied your
request. The Plan says this type of equipment is presumptively non-medical.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pennsaid 2% pump.
You asked the Plan to pre-approve Pennsaid. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pennsaid 2% pump.
Benefits for Pennsaid 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 an office visit (99215, 99205) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you need to continue services with this provider as they are able to assist with the procedure you need. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 provider at issue in this case is not a network provider with the Plan. 

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 office visit. Our reviewer says that the provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's clinical condition. Our physician reviewer found the record indicates that the enrollee was evaluated for cataract surgery. The plan has indicated that it has in network providers that are available and able to provide the needed 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 an office visit have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve an office visit. Therefore, we decided that the Plan does not have to pre-approve an office visit (99215, 99205) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the negative pressure wound therapy electrical pump provided from April 14, 2020, to June 14, 2020.

You asked the Plan to reduce the coinsurance for the negative pressure wound therapy electrical pump, stationary or portable (E2402). You say that you were never given any information that any further payments would be required. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Durable Medical Equipment. 

Providers have one year to file a claim. The claims were received on December 2, 2020 and paid on January 15, 2021 and February 18, 2021. You have been asked to pay 20% coinsurance for the negative pressure wound therapy electrical pump, stationary or portable (E2402). The negative pressure wound therapy electrical pump, stationary or portable (E2402) falls within the Durable Medical Equipment 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 reduce the coinsurance for the negative pressure wound therapy electrical pump provided from April 14, 2020, to June 14, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a facet joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested procedure is supported if the pain is mostly localized to the neck and does not travel to other areas of the body.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary. 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 injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the physical exam shows thoracic facet syndrome. The enrollee has tried physical and chiropractic therapy. There has been a trial of non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. The enrollee meets the criteria for diagnostic medial branch blocks. 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 injection have been met. Therefore, we decided that the Plan has to pre-approve a facet joint injection for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placements.

You asked the Plan to pre-approve the surgical implant placements. You say that you have a lot of pain and are requesting an appeal. The Plan denied your request. The Plan says replacing your teeth with implants is not the most cost-effective treatment plan and the least costly treatment option with be 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 services is not the most cost-effective treatment plan and will not be covered. Therefore, we decided that the Plan does not have to pre-approve the surgical implant placements.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial upper denture rebase (D5720).
You asked the Plan to pre-approve the partial upper denture rebase (D5720). You say that if you lose these teeth you will not be able to eat at all. You say that you need this done before you end up with an infection. The Plan denied your request. The Plan says the crown and core buildup will be covered, and the partial upper denture rebase is not a covered benefit.
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 the partial upper denture rebase (D5720).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies.
You asked the Plan to pre-approve the therapeutic continuous glucose monitor and supplies. You say that this requested equipment is medically necessary. The Plan denied your request. The Plan says the criteria for a therapeutic CGM have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on March 1, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
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 the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on March 1, 2021.
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 enrollee needs acute level of care. 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 in the Medicare rules section. 

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 knee replacement complicated by respiratory failure and cellulitis. Medical problems are stable. 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299).
You asked the Plan to pre-approve 6 additional skilled nursing visits. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the provided documentation does not support the need for 6 additional skilled nursing visits.
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 6 additional skilled nursing visits. Our reviewer says that the request for 6 additional skilled nursing visits is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has any skilled nursing needs. Therefore, the reviewer found that the requested home health skilled nursing services are not shown to be 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 6 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ultomiris for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this denial is appropriate given the clinical scenario.
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 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 drug. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the requested medication has similar mechanism of action and the need for less frequent infusions will result in considerably less morbidity on behalf of the enrollee (including exposure to potential community acquired infections). With the enrollee responding to Solaris, Ultomiris should also be effective. It is medically indicated and reasonable to switch medications. There is no reason to feel that Ultomiris should be less safe, and there are benefits from fewer disease and less exposure to risks involved. 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 drug have been met. Therefore, we decided that the Plan has to pre-approve Ultomiris for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care and a specialist office visit provided by participating providers on September 22, 2020, to January 11, 2021.

You asked the Plan to waive the copayment for wound care and a specialist office visit. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $225 copayment for outpatient surgery/in-network, and a $50 copayment and a $45 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a $225 copayment for wound care, and a $50 copayment and a $45 copayment for a specialist office visit.

Date of Service
Copayment

September 22, 2020
$225

September 29, 2020
$225

October 6, 2020
$225

October 13, 2020
$225

October 20, 2020
$225

November 3, 2020
$225

November 9, 2020
$50

November 23, 2020
$50

November 30, 2020
$50

December 7, 2020
$50

December 14, 2020
$50

December 21, 2020
$50

December 28, 2020
$50

January 4, 2021
$45

January 11, 2021
$45

Total Amount Being Asked to Pay: $1,790

Wound care falls within the outpatient surgery/in-network benefit category. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 wound care and a specialist office visit provided by participating providers on September 22, 2020, to January 11, 2021.
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 you are unable to care for yourself at home. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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 in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a metatarsal fracture after a fall
and for left anterior descending artery (LAD) stenting. Your medical problems are stable. There are 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placements (D6010) and
unspecified implant procedure (D6199).
You asked the Plan to pre-approve the surgical implant placements (D6010) and unspecified implant procedure
(D6199). You say that you are unable to eat, you have pain when you bite down and dentures will not stay in.
The Plan denied your request. The Plan says the services are not covered benefits.
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 the
surgical implant placements (D6010) and unspecified implant procedure (D6199).