Persius/hicric huggingface dataset:
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 SNF care. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee has exhausted the SNF benefit for this benefit period. The enrollee has used 100 days of SNF care and has not gone 60 days in a row without hospital or SNF care.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from October 29, 2019 to February 4, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilledcare in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay formedical supplies provided to the enrollee on March 5, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is evidence of misrepresented services.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 froman 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 Plandoes not haveto pay formedical supplies provided to the enrollee on March 5, 2019.
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 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 for infected hardware of the right knee. He underwent I/D, removal of hardware and placement of antibiotic spacer on 2/3/20. He returned to the operating room on 2/7/20 with removal of spacer and re-implantation of hardware. He will be on IV antibiotics until 3-20-20. His prior level of function was living alone in a single story home with one step to enter and has an aide 3 times per week for 20 hours. He was modified independent with mobility and activities of daily living. His current level of function is ambulating 120 feet with a rolling walker with standby assist, chairtransfer with supervision, toileting with supervision, supervision with bed mobility, and minimal assist with dressing and basic activities of daily living. Based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from continuing physical therapy 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-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 compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the compression garments. The Plan denied your request. The Plan says there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee walker.
You asked the Plan to pre-approve a knee walker. You say that your doctor recommended a knee walker to aid in your recovery and protect your non-weight baring foot. The Plan denied your request. The Plan says a knee walker does not meet the definition of DME and therefore is not considered a covered DME item.
The Plan must follow Medicare rules. The rules say that when there is no published policy for an item, contractors may make individual determinations when reviewing claims. The item at issue in this appeal is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a knee walker.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance was needed for an emergency situation. You say that you had fallen and someone called for an ambulance. The responders treated and evaluated you, eventually deciding that you were okay. You decided not to go to the hospital. You say there was no way to get prior authorization because the situation was an emergency. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 19, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 6, 2019 to August 9, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment because you were wrongfully admitted as an inpatient. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $325 copayment per day, for days 1-5 per admission. You have been asked to pay a $325 copayment for each day of the inpatient hospital stay. ($325 x 3 days = $975). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The medical record shows you received services while you were an inpatient.
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 the inpatient hospital stay provided from August 6, 2019 to August 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skillled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee does not require services that can only be provided as an inpatient in a skilled nursing facility.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's 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 skillled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that you cannot walk and need additional therapy and treatment.The Plan denied your request. The Plan says the 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 these services.Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you had a shoulder replacement surgery on February 10, 2020. You had stable vital signs and were effectively treated for pain. You received physical and occupational therapy in the hospital and need minimal assistance with transfers and varied levels of assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on August 30, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with the charges.
The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $300 copayment for ambulance services.
The enrollee has been asked to pay a $300 copayment for an ambulance trip. An ambulance trip falls within the
ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an
ambulance trip provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on May 15, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. You say that the member was referred by a provider. You say that you do not have access to the patient's insurance requirements.The Plan denied your request. The Plan saysthe referring provider, is out-of-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 pay for care from out-of-network providers only incases 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 referring provider is also out-of-network. 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 foroutpatient lab work provided on May 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair accessory electronic connection.
You asked the Plan to pre-approve power wheelchair accessory electronic connection (E2310). You say that the enrollee needs to control the power seat function through the joystick. The Plan denied your request. The Plan says the enrollee has adequate upper limb strength and function to be able to control the power options using their own switches.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 power wheelchair accessory electronic connection (E2310). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 4/5 right upper extremity strength with normal range of motion, per an April 18, 2019 mobility evaluation. The enrollee is noted to be at risk for pressure ulcers, and is independent with feeding and grooming. It is not medically necessary for the enrollee to control the seat tilt feature by the joystick instead of the integrated strength. The enrollee's strength in the right upper extremity is sufficient to control the power options with their separate switches already included with the approval of these power options. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair accessory electronic connection (E2310) have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair accessory electronic connection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transvaginal ultrasounds provided on September 11, 2019.
You asked the Plan to waive the copayment for transvaginal ultrasounds. You say that you cannot afford 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 Centennial Plan
members must pay a $300 copayment for ultrasounds.
You have been asked to pay $175.13, which is less than the $300 copayment for transvaginal ultrasounds.
Transvaginal ultrasounds fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for transvaginal ultrasounds provided on September 11, 2019.
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-approvethe LTACH services. You say that the services are medically necessary.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 is currentlyundergoing treatment at an acute care hospital (ACH) following revision of a lower extremity amputation. The enrollee is not intubated/ventilated. 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.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 topre-approvelong term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis and has failed oral alendronate. The records do not show that she has tried and failed the Plan's required drug of Reclast or that the required drug would be less effective or contraindicated. Prolia is therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 11,
2019.
You asked the Plan to waive the copayment for the ED visit. You say that the staff encouraged you to go to the
emergency room. You say that you did not expect to get a bill. The Plan denied your request. The Plan says the
copayment 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 $75
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $75 copayment for the ED visit. The ED visit falls within the "Emergency care"
benefit category. The records show that you were treated in the ED. 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 the ED visit provided on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mexiletine capsules.You asked the Plan to pre-approve Mexiletine capsules. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Mexiletine capsules are not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Mexiletine capsules.Benefits for Mexiletine capsules may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.You asked the Plan to pre-approve the physician's services. 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 anin-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 care that cannot be provided by network providers.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 to be provided.