Persius/hicric huggingface dataset:
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 services are medically necessary.The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility he is in. Therefore, coverage criteria has not been 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a motor vehicle collision resulting in multiple spine and rib fractures. The enrollee remains on a ventilator, but is starting to tolerate weaning and does appear to be neurologically intact. It is difficult to know when the enrollee's chest, weakened by multiple bilateral rib fractures, will be stable and strong enough for him to breathe on his own. The enrollee does appear to be getting appropriate care in his current setting. 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. The enrolleecan then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmological services provided on July 25, 2019.You asked the Plan to waive the copayment forthe ophthalmological services. You say that you should not be paying a copayment for every visit.The Plan denied your request. The Plan says the benefits were 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 you must paya$30 copayment for Vision Care, Medicare-covered eye exam. You have been asked to paya$30 copayment for the ophthalmological services. The ophthalmological services falls within the Vision Care, Medicare-covered eye exam 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 forophthalmological services provided on July 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp for the enrollee.You asked the Plan to pre-approveAranesp. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee. Our physician reviewer found thatthe enrollee's condition does not meet criteria for Aranesp. Documentation does not support an inadequate response to Retacrit (epoetin alfa) therapy for at least two consecutive months with appropriate dose adjustment or outline contraindications or reasons this medication was not considered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does nothave to pre-approveAranesp for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-ray s(D0272) provided on August 22, 2019 by the out of network provider.You asked the Plan to reimburseyou forthe dental services. You say that you the provider's office tried multiple times to submit the claim with no success. You say that you were not made aware that a there was a time limit to file a claim.The Plan denied your request. The Plansays the time limit for filing the claim has expired. The Plan also says that you did not call the Plan regarding the claim for the August 22, 2018 date of service until April 4, 2019.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 and the services are listed as covered, you must submit a bill showing paid in full to the provider when you receive the services out of network and are seeking reimbursement.Additionally, the record shows you did not contact the Plan regarding the claim until April 4, 2019, well passed the 60 day filing limit.Therefore, we decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-ray s(D0272) provided on August 22, 2019 by the out of network provider.
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 inpatient rehabilitation level of care isnecessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require the intensive physician or nursing oversight that is present in an IRF. While you may benefit from and participate in additional therapies such as physical therapy (PT) and occupational therapy (OT), the documentation does not indicate that your functional level requires this therapy on an intensive IRF level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement socket.You asked the Plan to pre-approve a replacement socket. You say that  The Plan denied your request. The Plan says that they do not know that your leg is at a stable level with swelling and shape to fit you for a definitive device in such a short time.The Plan follows Medicare rules. Medicare rules say that a replacement socket is covered if certain criteria are 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 replacement socket. Our reviewer says that a replacement socket is not medically reasonable and necessary in this case. The documentation does not reveal objective measurements that indicate there have been changes in the residual limb or evidence of wear/tear due to excessive weight or prosthetic demands of very active amputee. It is unclear whether your limb size is stable for afitting of a definitive prosthetic limb at this time as your amputation was only three months ago. Our physician reviewer found that your condition does not meet criteria for a replacement socket.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 replacement socket have not been met.Therefore, we decided that the Plan does not have to pre-approvea replacement socket.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 standard power wheelchair (K0841) and accessories.You asked the Plan to pre-approvea Group 2 standard power wheelchair (K0841) and accessories. You say that the enrollee needs a replacement power wheelchair.The Plandenied your request. The Plan says the enrollee does not meet criteria for power tilt and recline.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 2 standard power wheelchair and accessories. Our physician reviewersays aGroup 2 standard power wheelchair (K0841) with power tilt and reclining seat is not medically necessary.The documentation indicates that the enrollee has a mobility deficit however the documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, utilizes intermittent catheterization for bladder management,is unable to independently transferfrom the wheelchair to bed;  or that the power seating system is needed to manage increased tone or spasticity.
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 Group 2 standard power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 standard power wheelchair (K0841) and accessories
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean epidural steroid injection and medial branch block.You asked the Plan to pre-approvethe epidural steroid injection and medial branch block. You say that these services are medically necessary because you are in so much pain that you struggle to walk.The Plan denied your request. The Plan says there is no documentation that you have tried physical therapy.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physicianreviewer 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 epidural steroid injection and medial branch block. Our reviewer says that you do not meet Medicare coverage criteria for the epidural steroid injection and medial branch block. Our reviewer found the medical records provided do not document your response to physical therapy. The medical documentation provided do not include imaging results, nor your response to non-surgical, non-injection 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 the epidural steroid injection and medial branch block have not been met.Therefore, we decided that the Plan does not have to pre-approvean epidural steroid injection and medial branch block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair, not otherwise classified (CPT Code K0898)You asked the Plan to pre-approvethe DME. You say that the durable medical equipment is medically 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 DME have not been met. The notes show you were seen by an expert on November 7, 2019, the report showed you can walk within your home with the use of your walker and drive your own car. Based on the report, a Power Wheelchair/Powered Operated Vehicle (Scooter) would not be medically necessary at this time.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair, not otherwise classified (CPT Code K0898)
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pay forthe surgical assistant services provided during spinal surgery on June 5, 2019 described by codes 22845-AS-59 and 22585-AS-59.You asked the Planto pay forthe surgical assistant services. You say that these services should be paid as they are payable for surgical assistant services and were medically necessary.The Plandenied your request. The Plansaysthatreimbursement for Assistant Surgeon services, as indicated by modifiers 80, 81, 82, or AS is not allowed for procedures where reimbursement has been provided for eligible Co-Surgeon services (L5-S1), using the same surgical procedure code, during the same encounter.The Plan must follow Medicare rules. The rules say that Medicarehealth 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. In this case, the Plan does not dispute that the services described by these codes were documented in the operative report. The denial is based on the assertion that assistant at surgery payment cannot be made when payment has been made for co-surgeon services during the same encounter. However, the Plan has not provided any citation which states this. The reviewer has been unable to find any citation which prohibits payment for surgical assistant services rendered during asurgery in which two primary surgeons perform part of the procedure. There is also no evidence provided to show that any of these services were billed and paid as co-surgeon procedure via a -62. Without a clear citation nor evidence that co-surgeon payment was made, we find that this denial is not supported.Therefore, we decided that the Planhas to pay forthe surgical assistant services provided during spinal surgery on June 5, 2019 described by codes 22845-AS-59 and 22585-AS-59.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance applied ($58.39) for anesthesia services provided on June 24, 2019.You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct because you were admitted to the hospital.The Plan denied your request. The Plan says this coinsurance was applied based on the services provided and the plan contract agreement. The Plan says that this was an outpatient surgical procedure and copayment for the anesthesia applies.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 Medicare Part B drugs administered by a physician or medical staff. 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 waivethe coinsurance applied ($58.39) for anesthesia services provided on June 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe knee brace provided on May 29, 2019.You asked the Plan to waive the coinsurance forthe knee brace. You say that the product you received is not what was described. You say that you should only pay for what you received.The Plan denied your request. The Plan says the coinsurance 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 you must pay 20% coinsurance for Medicare-covered durable medical equipment.You have been asked to pay $120, which is 20% of the allowed amount for the knee brace. The allowed amount is $600 (20% x $600 = $120). The knee brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe knee brace provided on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forwellness lab screening tests.You asked the Plan to pay forwellnesslab screening tests. You say that this testing should be covered by the Plan.The Plan denied your request. The Plan says this type of testing is not covered by Medicare.The Plan follows Medicare rules. The rules explicitly say that screening tests, except forthe few tests listed above, are not covered. Thetest at issue in this appeal, wellness lab screening tests, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forwellness lab screening tests.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe upper eyelid surgery provided on August 22, 2019.You asked the Plan to waive the coinsurance forthe upper eyelid surgery. You say that you should not be responsible for this amount because this was a repeat surgical procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.Therules 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% of the total cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or facility charges, observation room/stay charges, physician charges and surgical charges. You have been asked to pay a total coinsurance amount of $411.66 for the upper eyelid surgery. The upper eyelid surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. See chart below.Date of ServiceServiceProviderAllowed AmountCoinsuranceMember LiabilityAugust 22, 2019Eyelid surgeryPhysician$907.3420%$181.47August 22, 2019Eyelid surgeryFacility$1,150.9520%$230.19Total$411.66
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe upper eyelid surgery provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to "the doctor", an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this provider has treated you in the past.The Plandenied your request. The Plansaysthe services can be provided in the plan's network.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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to "the doctor", an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Euflexxa.You asked the Plan to pre-approveEuflexxa. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for Euflexxa is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Euflexxa.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 todetermine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The record does not show that these drugs would likely be less effective for the enrollee, or likely have adverse effects.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Euflexxa.