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

We decided that the Plan does not have to waive the copayment for emergency care provided on November 24, 2019.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you already paid the $50 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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living care (99336) provided on May 22, 2020.

You asked the Plan to pay for the assisted living care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers 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 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 assisted living care (99336) provided on May 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMethylphenidate 10mg tab for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication falls under Part D coverage.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 Plandoes not haveto pre-approveMethylphenidate 10mg tab for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on March 29, 2019. You asked the Plan to pay for the electric stimulation therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 97014 is not recognized for Medicare and there are alternate codes which can be used to support this service. 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 97014 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on March 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the sanitation service (D1999) provided on September 23, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sanitation service (D1999) provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCGPtesting by use of individual test (CPT Code 81455) provided on August 9, 2020.You asked the Plan to pay forthe testing. You say that the testing is necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPTcode 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEXZ-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care.Therefore, we decided that the Plan does not have to pay forCGP testing by use of individual test (CPT Code 81455) provided on August 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRetacrit.You asked the Plan to pre-approveRetacrit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Retacrit. Our reviewer says that the documentation does not support that therequested drug is medically reasonable or necessary.Our physician reviewer found the enrollee has iron deficiency anemia. Review of documentation does not support the beneficiary has a diagnosis supported by compendia or FDA approved uses for Retacrit. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approveRetacrit
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duragesic 50 mcg/Hr 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 the medication falls under the Part D 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 Duragesic 50 mcg/Hr for
the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.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 the documentation doesnot support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 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 care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe additional surgical removal of erupted tooth services (D7210).You asked the Plan to pre-approvethe surgical removal of erupted tooth. You say that you are in pain and need these services.The Plan denied your request. The Plan says the coverage for dental extractions has been exhausted.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. The Plan covers the surgical removal of erupted tooth three times per calendar year.We looked at file and Medicare rules. The file indicates that the Plan has approved 3 teeth extractions. Therefore, the extraction services have been exhausted and the request for additional extractions will not be approved by the Plan. Based on this information, we decided that the Plan's rules for coverage of the additional surgical removal of erupted tooth have not been met.Therefore, we decided that the Plan does not have to pre-approvethe additional surgical removal of erupted tooth services (D7210).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveCarboplatin injection 50 mg (J9045).You asked the Plan to pre-approveCarboplatin. You say that this service is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not medically necessary or supported by relevant compendia.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 Carboplatin. Our reviewer says that the service is medically necessary and reasonable. Our physician reviewer found this is a patient with late line treated metastatic breast cancer. There is support for palliative treatment with Carboplatin as late line therapy to patients with metastatic breast cancer.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin have been met.Therefore, we decided that the Plan has to pre-approveCarboplatin injection 50 mg (J9045).If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admittedto the current acute care hospital with worsening confusion and low oral intake. He was diagnosed with sacral wound and sepsis and was treated with fluids and antibiotics. He required pressor support and wound debridement of necrotic tissue. He required intubation but later was extubated successfully and no longer requires oxygen. Currently he requires basic wound care, additional antibiotic treatment, and kidney function monitoring which is improving.The enrollee appears to be improving but requires only short-term additional acute care services which can be safely administered at the current acute care setting. The enrollee does not require services at the LTACH that are not already available and covered at the current setting. There are no services at the LTACH that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary at this time.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-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF 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 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 pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that youreceived enteral nutrition and medications. Youhad stable vital signs. You weredependent with functional mobility and activities of daily living. The documentation does not support that you requirethe specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you donot require the necessary services on an inpatient basis, at a SNF 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-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe semi-electric hospital bed.You asked the Plan to pre-approvethe semi-electric hospital bed. You say that you do not have a bed at home,and you have recently gotten out of the hospital due to an amputation.The Plan denied your request. The Plan says the enrollee does not meet Medicare coverage criteria;the records do not show specifics.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible withan ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrolleestates he was in the hospital for fivemonths and came home threedays ago. The member was in the hospital due to a right foot amputation. The member states he has no bed at home. He only has a recliner which he sleeps in and a chair. He also has a table.The review has determined that the requested hospital bed is not medically necessary for this patient.
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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approvethe semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis provided on October 12, 2020.You asked the Plan to pay forthe prophylaxis. You say that you were unable to get the first cleaning done until June because you had knee surgery. You also say that you feel the Plan should be liable to the second cleaning.The Plan denied your request. The Plan says this claim processed correctly.Medicare generally does not cover dental services. However, thePlan 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, prophylaxis is limited to up to 1 visit every six months. The record shows that you received a prophylaxis on June 8, 2020, and your prophylaxis benefit had been exhausted through December 8, 2020.Therefore, we decided that the Plan does not have to pay forthe prophylaxis provided on October 12, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that discharge would prolong the enrollee's time to regain her function and prevent her from getting better.The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill,knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF care have notbeen met.Therefore, we decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care.
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 enrollee is ready to discharge from the hospital and would benefit from IRF.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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 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.