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

We decided that the Plan does not have to waive the coinsurance for an infusion and copayment for physician services provided by a participating provider on November 12, 2020.

You asked the Plan to waive the coinsurance for an infusion and copayment for physician services. You say that you have only ever paid $200 before for this. The Plan denied your request. The Plan says the correct coinsurance and copayment have been applied.

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 20% coinsurance for Medicare Part B prescription drugs/in-network and a $50 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a 20% coinsurance of the allowed amount for an infusion and a $50 copayment for physician services. The total allowed amount is $3,809.60. The amount you are being asked to pay for an infusion is $761.92 ($3,809.60 x 20% = $761.92). The total amount you are being asked to pay is $811.92 ($761.92 + $50 = $811.92). An infusion falls within the Medicare Part B prescription drugs/in-network benefit category and physician services fall within the physician/practitioner services/in-network/specialist 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 an infusion and copayment for physician services provided by a participating provider on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 26, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you should not have to pay the copayment because you were waiting for results of the COVID test. The Plan denied your request. The Plan says you have been asked to pay 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 $490 copayment for each Medicare-covered day for days 1-4 and a $0 copayment for each additional day. You have been asked to pay a $490 copayment on each day, for days 1-4 of the inpatient stay. ($490 x 4 = $1,960). The inpatient stay falls 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 the inpatient stay provided from November 26, 2020.
Your complaint about the type of COVID-19 test you received is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective coating (V2750).

You asked the Plan to pay for the anti-reflective coating. You say that the anti-reflective coating should be covered under your benefit. The Plan denied your request. The Plan says the services received were done post- cataract surgery, which applies to your Vision Hardware (Medicare-covered) post-cataract benefit, therefore the anti-reflective coating is excluded from your supplemental (non-Medicare covered) benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided as part of routine (non-Medicare covered) care, or when it is medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner.

We looked at the file and the Plan's rules. The vision care in this case is being provided as part of post-cataract care, therefore the Plan's routine (non-Medicare covered) benefit does not apply. In addition, Medicare rules state that anti-reflective coating (V2750) is covered only when it is medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating (V2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.

You asked the Plan to pre-approve the acupuncture services. You say that you would like reconsideration because you are in pain and the acupuncture will provide relief. The Plan denied your request. The Plan says the documentation does not show that you have chronic lower back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation submitted does not indicate that you have chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is an 84-year-old female with a Stage III sacral ulcer. In this case, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).
You asked the Plan to pre-approve an expandable controller. You say that the expandable controller is
medically necessary. The Plan denied your request. The Plan says the criteria for an expandable controller have
not been met.
The Plan follows Medicare rules. Medicare rules say that the expandable controller is subject to the criteria
listed in the Medicare rules section.
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 an expandable controller. Our reviewer
says that the requested expandable controller is not medically necessary and reasonable. Our physician
reviewer found the enrollee is a 56-year-old male with a past medical history of paraplegia who requires a
power wheelchair for mobility. Based on the medical records provided there is no documentation that an
expandable controller is medically necessary. In this case, the records indicate he is able to drive a car using
upper extremity controls and has 3-4/5 upper extremity strength - this information indicates his upper extremity
strength and function are adequate to control the power options using own switches.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan
does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and only requires additional short-term acute care services which can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed. 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
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 there is no documentation of clinical complexities that require daily complex skilled nursing needs or an existing debility that makes care at home unsafe.

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-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on September 10, 2020.
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99232 is not supported in the medical record. Specifically, this code was billed with a secondary diagnosis code of N18.30 (chronic kidney disease, stage 3 unspecified). This diagnosis code did not go into effect until October 1, 2020, which is after the date of service at issue. This means that this diagnosis code is invalid. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on September 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for group psychotherapy provided on March 31, 2020.
You asked the Plan to pay for the group psychotherapy. The Plan denied your request. The Plan says 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 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 group psychotherapy provided on March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 28, 2020, to October 1, 2020.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the inpatient care is 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 the 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 that the enrollee is a 43-year-old bed-bound male who presented to the emergency department with leg pain and fever. The provided records did not show sufficient supportive information for admission status. The enrollee was hemodynamically stable and was not expected to require hospital services that would cross 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 the acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from September 28, 2020, to October 1, 2020.
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 this care is medically necessary. The Plan denied
your request. The Plan says IRF care is not medically necessary as you needs can be met at a lower level of
care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 you are an 83-year-old male who was admitted to an acute care hospital on April 11,
2021. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to
require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can
be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopic meniscectomy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no clinical information documenting medical necessity.
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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive
less invasive conservative care measures, as therapy is noted from 2011. Furthermore, she is noted to have
mechanical symptoms on 4/13/21. However, these are not described in detail, nor fully corroborated by exam
findings. There is no compelling rationale presented or extenuating circumstances noted to support the medical
necessity of this request as an exception to guidelines. Therefore, the request for arthroscopic meniscectomy is
not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve arthroscopic meniscectomy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer (Coflex) device.

You asked the Plan to pre-approve an interspinous spacer device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 an interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have back pain. Interspinous spacer devices remain experimental. More research is needed to show safety and efficacy. Therefore, you do not meet criteria for the requested 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 an interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer (Coflex) device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy for the enrollee.
You asked the Plan to pre-approve Yervoy. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Yervoy. Our reviewer says that Yervoy
is not medically reasonable and necessary for the enrollee. Yervoy is not FDA-approved for the enrollee's
diagnosis as a single agent. The use of Yervoy is not supported by one of the major drug compendia or by
clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of Yervoy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to
pre-approve Yervoy for the enrollee.