Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection of ropivacaine hydrochloride (J2795), and injections of lower or sacral spine facet joint using imaging guidance (64493, 64494) provided from May 20, 2019 through August 12, 2019.
You asked the Plan to waive the copayment for injections. You say that the copays should be waived because this is the same exact same thing you had done in 2018 with the same exact provider and operating room and everything. The Plan denied your request. The Plan says outpatient surgery services have a $250 copayment per day performed in an outpatient hospital or ambulatory surgical center.
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 $250 copayment for outpatient surgery services. You have been asked to pay a $250 copayment for each date of service for injections. This service falls within the outpatient surgery services benefit category. The record shows your services were rendered on 4 dates of services: May 20, 2019, June 14, 2019, July 15, 2019, and August 12, 2019 (4 x $250 = $1,000). 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 an injection of ropivacaine hydrochloride (J2795), and injections of lower or sacral spine facet joint using imaging guidance (64493, 64494) provided from May 20, 2019 through August 12, 2019.
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. The Plan denied your request. The Plan says the enrollee does not require an intensive, multi-disciplinary team approach to therapy, or close physician monitoring.
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 physician reviewer found that the enrollee's current level of function is contact guard assist with grooming, bathing, and toileting, contact guard assist with transfers, supervision with upper body dressing, contact guard assist with lower body dressing, and ambulating 90 feet then 40 feet with a rolling walker with supervision. The enrollee is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided by from March 4, 2019 to October 18, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the
charges. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs from March 4, 2019 to October 18, 2019. Therefore, you are responsible
to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service Service Allowed Amount Amount You Owe
3/4/2019 J0517 $5,011.20 $1,002.24
6/28/2019 J0517 $5,006.40 $1,001.28
8/23/2019 J0517 $5,065.20 $1,013.04
10/18/2019 J0517 $5,055.00 $1,011.00
The total amount you owe is: $4,027.56.
You have been asked to pay the total coinsurance amount of $4,027.56 for Medicare Part B drugs. Medicare
Part B drugs fall within the Medicare Part B prescription drugs 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 for Medicare Part B drugs provided from March 4, 2019 to
October 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the requested continuation of SNF care does not meet criteria.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 the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF level of care on 1/15/20 following inpatient admission for right shoulder surgery. The enrollee is hemodynamically stable and afebrile. Skin is healing. Functionally, the enrollee is supervised for mobility, basic activities of daily living and transfers. Pain appears controlled. There is no bowel or bladder deficit. The enrollee is now mostly supervised for all care. The enrollee has no complex wound care needs or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable; the enrollee is tolerating an oral diet; has no significant bowel or bladder deficits; and pain is controlled. SNF care is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of skilled nursing facility (SNF) care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF)care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 28, 2019 and July 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on June 28, 2019 and July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's doctors feel that she meets requirements for 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 records do not indicate that there are significant or complex medical and nursing issues that could not be addressed at a Skilled Nursing Facility (SNF) level of care. Ongoing medication management, skin care, and daily therapy can be provided at a SNF. In this case a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212) provided on February 5, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you are requesting further review for reconsideration of payment as the notes support the need for services.The Plan denied your request. The Plan says they have non-network providers who do not work with the member's health plan.The member self-directed for care. The member's primary care provider did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules saythat plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99212) provided on February 5, 2019 by out of network provider,
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided from July 11, 2019 to July 31, 2019 by an out of network provider.You asked the Plan to pay forthe therapy services. You say that upon the enrollee's admission you were under the impression that authorization was not required. You also say that the appropriate disciplines completed evaluations as deemed medically necessary by the therapist and with consultation of the physician and enrollee.The Plan denied your request. The Plan says the enrollee sought services through a non-plan provider withoutprior 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe therapy services provided from July 11, 2019 to July 31, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental splint.
You asked the Plan to pre-approve a dental splint. You say that a mouth guard will prevent your condition from getting worse. The Plan denied your request. The Plan says a diagnosis of temporomandibular joint syndrome (TMJ) is insufficient evidence for coverage.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. We looked at the file and Medicare rules. Your diagnosis code is considered to be routine dental diagnosis code and is excluded from Medicare payment. Based on this information, we decided that Medicare rules for coverage of an occlusal dental splint have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental splint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (CPT G0438) provided on August
28, 2019.
You asked the Plan to pay for the physician's services. You say that you were in a lot of pain and the nearest
urgent care or emergency room is 45 miles from your home. The Plan denied your request. The Plan says your
plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty
network. Non-emergent, non-urgent services with
out-of-network providers require 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 contract with the Plan also says that your plan requires you
to receive care from providers who are part of your primary care physician's (PCP) specialty network.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
annual wellness visit. We found no exception that would require the Plan to pay for the annual wellness visit.
Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on August 28,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care for progressive weakness and weight loss. Concern was for malignancy given elevated alkaline phosphatase. The enrollee was provided with bone scan and X-ray imaging. He has chronic atrial fibrillation and is anticoagulated. The enrollee is now hemodynamically stable and afebrile. The enrollee is moderate assist for transfers and maximum assist for lower body activities of daily living. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) of the brain.
You asked the Plan to pre-approve the MRI. You say that a follow-up MRI recently showed the presence of a
lesion within the previous resection cavity suggesting recurrent neoplasm. The Plan denied your request. The
Plan says this is an investigational procedure.
The Plan must follow Medicare rules. Medicare rules say that MRS is considered investigational.
The requested procedure cannot be covered Based on this information, we decided that Medicare rules for
coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve
magnetic resonance spectroscopy (MRS) of the brain.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prednisone tablets. 
 
You asked the Plan to pre-approve prednisone tablets. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 prednisone tablets.  
 
Benefits for prednisone tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on September 10, 2019.You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on September 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided at the facility.
You asked the Plan to pre-approve the physician's services. You say that you would like a second opinion out
of plan based on the extreme rarity of the situation and you need to do due diligence in this situation
effectively. The Plan denied your request. The Plan says you must receive care from in-network providers with
the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the
care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services for a second opinion to be provided at the facility.