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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 10, 2020, through May 14, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel as though this is a duplicate charge. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment each time you are admitted to an acute care hospital for inpatient hospital care. 

You have been asked to pay a $200 copayment for an inpatient hospital stay. The services at issue fall within the inpatient hospital 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 an inpatient hospital stay from May 10, 2020, through May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 20, 2019, through October 22, 2019.

You asked the Plan to pay for acute inpatient hospital care. You say that the services at issue were an emergency and medically necessary. The Plan denied your request. The Plan says the services at issue do not meet inpatient criteria.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was hemodynamically stable without the need for hospital care that would be expected to cross 2 midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 20, 2019, through October 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.

You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Brovana. Our reviewer says that
Brovana is not medically reasonable and necessary. Our physician reviewer found you have not tried and failed
the required drug, Perforomist (Formoterol). Our reviewer also found that there is no indication that the Plan's
required drug would likely be less effective and/or likely have adverse effects for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have
to pre-approve Brovana.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer (J1439).

You asked the Plan to pre-approve Injectafer. You say that your iron levels are extremely low, and this drug
should not be denied because you need it. The Plan denied your request. The Plan says you do not have anemia.

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 Injectafer. Our reviewer says that
Injectafer (J1439) is not medically reasonable and necessary. Our physician reviewer found the documentation
does not support that the Injectafer (J1439) is safe and effective for you. Our reviewer found that you do not
have an iron deficiency anemia. Our physician reviewer also found that you have not tried an oral iron
supplementation and cannot take them.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer (J1439).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says that the 
enrollee has no acute medical conditions. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient services. Our physician 
reviewer found that inpatient treatment for Electroconvulsive Therapy (ECT) was requested. Services are 
reasonably expected to improve your condition or for the purpose of diagnosis. The requested admission does 
meet the criteria for acute inpatient mental health treatment as you are shown to be a danger to yourself but not 
others, without agitation or aggression, and without perceptual disturbance including auditory or visual 
hallucinations. It does appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than 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 inpatient services have been met. Therefore, we decided that the Plan has to pre-
approve inpatient psychiatric services.  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits.
You asked the Plan to pre-approve home health. You say that discontinuing physical therapy at this point would adversely affect the enrollee's functional mobility and safety. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
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 home health. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found the enrollee appears to be functioning at a level that no longer requires in-home skilled physical therapy services. The enrollee's care needs can be met at a lower level of care such as outpatient therapy or a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz.
You asked the Plan to pre-approve Xeljanz. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit. The Plan also says that outpatient prescription drugs are not covered by the enrollee's plan.
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 Xeljanz.
Benefits for Xeljanz 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lodging, meals and transportation (S9975), ground mileage (A0425), and unlisted special service (99199) obtained from June 27, 2020, to July 3, 2020.

You asked the Plan to pay for the lodging, meals and transportation. You say that you would like the Plan to check if you can be reimbursed for any expenses. The Plan denied your request. The Plan says this type of service is only covered when you must travel to receive an organ transplant.

The Plan must follow Medicare rules. Medicare rules say that the Plan provides transplant services at a location outside of the pattern of care for transplants in your community and you chose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion.

We looked at the file and Medicare rules. In this case the record does not show that your lodging, meals and transportation costs were related to travel for transplant services. Based on this information, we decided that Medicare rules for coverage of the lodging, meals and transportation have not been met. Therefore, we decided that the Plan does not have to pay for the lodging, meals and transportation (S9975), ground mileage (A0425), and unlisted special service (99199) obtained from June 27, 2020, to July 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 15, 2021, to April 16, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like to appeal the inpatient stay. The Plan denied your request. The Plan says the inpatient stay was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 15, 2021, to April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on March 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 for an office visit (99213) provided on March 12, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on April 20, 2021.
You asked the Plan to pay for the complete maxillary denture and mandibular partial denture. You say that your previous dentures were not made correctly, and you needed new ones. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a complete maxillary denture (D5110) on February 10, 2020 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on April 20, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving the appropriate care in the Inpatient Rehabilitation Facility.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on August 19, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 for an office visit (99204) provided on August 19, 2020, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 skilled nursing visits, 2 medical social work visits, 4 occupational therapy services, and 4 physical therapy visits.
You asked the Plan to pre-approve home health services. You say that you are legally blind. You say that you are on oxygen. You also say that you need these services. The Plan denied your request. The Plan says there is no evidence that you are homebound or unable to leave your home for the requested services. The Plan also says that being homebound is a requirement to receive home health care.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-approve 4 skilled nursing visits, 2 medical social work visits, 4 occupational therapy services, and 4 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control (E2331), adjustable height armrests (E0973), a power seat elevation feature (E2300), a toggle switch (K0108), a custom frame (K0108), and push handles (K0108).
You asked the Plan to pre-approve an attendant control, adjustable height armrests, a power seat elevation feature, a toggle switch, a custom frame, and push handles. You say that the enrollee needs these items. The Plan denied your request. The Plan says these items are not covered.
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. Adjustable height armrests (E0973) are included in the allowance for the corresponding power tilt and/or recline seating systems (E1007) when provided at the same time. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. Code K0108 also may not be billed for nonstandard dimensions of a power tilt and/or recline seating system (E1002, E1003, E1004, E1005, E1006, E1007, E1008). A power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. The attendant control, adjustable armrests, and toggle switch are included in or cannot be approved separately from other items that have been approved by the Plan in this request. The requested custom frame is considered to be nonstandard dimensions of a power tilt and/or recline seating system and cannot be requested with code K0108. The requested power seat elevation system is a non-covered item. Based on this information, we decided that Medicare rules for coverage of an attendant control, adjustable height armrests, a power seat elevation feature, a toggle switch, a custom frame, and push handles have not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant control (E2331), adjustable height armrests (E0973), a power seat elevation feature (E2300), a toggle switch (K0108), a custom frame (K0108), and push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on March 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.

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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 for an office visit (99214) provided on March 1, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950) provided on April 27, 2021.
You asked the Plan to pay for a core buildup. You say that the service was pre-approved and should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one procedure per tooth every 5 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a core buildup have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on April 12, 2019. Therefore, we decided that the Plan does not have to pay for a core buildup (D2950) provided on April 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron (J8597).

You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says Ondansetron is a self-administered drug. The Plan also says that Ondansetron does not fall under Part B 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 Plan does not have to pre-approve Ondansetron (J8597).

Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.