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

We decided that the Plan does not have to pre-approve MRI of bilateral breast.
You asked the Plan to pre-approve the MRI. You say that you are at high risk for breast cancer, due to hormone replacement therapy for greater than ten years. The Plan denied your request. The Plan says a review of the medical records do not show that an ultrasound has been completed, or that the MRI is needed to guide a biopsy of the mass.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no genetic mutation such as BRCA-1 or 2 documented within the given records. In addition, there is no Gail Risk pattern documented showing a greater than 20% lifetime risk of breast cancer in the submitted records. The mammogram reports have been unequivocally benign with annual screening advised. The accepted criteria for breast MRI are thus not met. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of bilateral breast.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 8, 2020 through January 17, 2020. You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 8, 2020 through January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) provided on February
5, 2020.
You asked the Plan to pay for MRI. You say that you are appealing with supporting records. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because this claim was billed with
Place of Service (POS) code 22 for outpatient hospital however the enrollee was a hospital inpatient at the time
of service.
The Plan must follow Medicare rules. Medicare rules say that if a provider performs the professional
component of a diagnostic test, the Place of Service (POS) code assigned to the claim will be the setting in
which the enrollee received the technical component of the service.
We looked at the file and Medicare rules. The service billed on this claim is the professional component of an
MRI. This service was performed during the course of a hospital inpatient stay, therefore the Place of Service
(POS) code 22 - indicating an outpatient hospital setting - is not appropriate for this claim. Based on this
information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided
that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the stair life purchased on September 11, 2019. You asked the Plan to reimburse you for the stair lift. You say that you live in the basement, there is 15 steps up to the living area and you had fallen down the stairs. The Plan denied your request. The Plan says a stair lift is a convenience item not primarily medical in nature.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to reimburse you for the stair life purchased on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forgenetic testing for the enrollee.You asked the Planto pay forthe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthis testing is considered experimental and not a covered benefit.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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Per the laboratory requisition, the enrollee has prostate cancer. Testing specifically related to her prostate cancer and for which associated therapies are known, was/is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to prostate cancer or for which there are no associatedtherapies, was/is not medically necessary or reasonable. The documentation does not support that the requested panel testing was/is medically necessary or reasonable. 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 testing have not been met.Therefore, we decided that the Plandoes not haveto pay forgenetic testing for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not need for intensive rehab, physician supervision, and a multidisciplinary team for 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 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 is generally medically stable with deconditioning. There are no recent neurological or orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently, the enrollee is at a supervision to minimal assist level. While the enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on March 9, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that this is a covered service and you should not owe anything. The Plan denied your request. The Plansays 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 clearlysays that you must pay a $200 copayment per visit for all other outpatient and therapeutic services and supplies, such as MRAs, MRIs, CT scans, PET scans, and hyperbaric oxygen therapy.You have been asked to pay a $200 copayment for the CT scan. The CT scan falls 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 forthe CT scan provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
February 7, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a pre-operative
service to your surgery. You say you should not be charged the copayment. 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 $15
copayment for each specialist visit for Medicare-covered services.
You have been asked to pay a $15 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there
is no provision in the contract which indicates a copayment would be waived if performed as a pre-service
appointment to a surgical procedure.
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 specialist office visit provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 6, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit and nerve study. You say that your right to recover payment for services is not extinguished by Plan requirements such as network participation or direct payments to enrollees.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and services were not urgent or emergent.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 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 medical services provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after July 13, 2020.You asked the Plan to pre-approve continued SNF care. You say that the enrollee cannot return to her assisted living facility until the results of a negative COVID-19 test have been received.The Plan denied your request. The Plan says the denial of authorization for continued Skilled Nursing Facility (SNF) care after July 13, 2020 is correct.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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after July 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and a surgical pathology procedure provided on January 7, 2020.You asked the Plan to waive the copayments for a colonoscopy and a surgical pathology procedure. You say that a polyp was removed during a colonoscopy screening and you feel that you should not be charged a copayment.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 a $200 copayment for outpatient hospital surgery services and a $20 copayment for all other services received in an outpatient hospital facility.You had a polyp removed during a colonoscopy on January 7, 2020. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 copayment. You had a surgical pathology procedure on January 7, 2020 at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $5.89, which is less than the $20 copayment. The total amount you owe is: $205.89.  Youhave been asked to pay the total copayment amount of $205.89 for a colonoscopy and a surgical pathology procedure. A colonoscopy and a surgical pathology procedure fallwithin the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments fora colonoscopy and a surgical pathology procedure provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 29, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that your right to recover payment for services is not extinguished by Plan requirements such as network participation or direct payments to the enrollee.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and a valid referral was not obtained.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 medical services provided on July 29, 2019 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 endodontic therapy (root canal) molar (D3330) provided December 12, 2019. You asked the Plan to pay for the dental services. You say that you request an exception for coverage since your dentist referred you to his brother for a root canal and said it was covered. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered 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. Page 36 of the health plan contract specifically says you must receive your care from a network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (root canal) molar (D3330) provided December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee's medical condition is too complex for any skilled nursing facility.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee is currently undergoing treatment at an acutecare hospital (ACH) for CoViD-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is tolerating ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine HCl.You asked the Plan to pre-approve Hydroxyzine HCl. You say that the Hydroxyzine HCL is medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B Medical 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 Hydroxyzine HCl.Benefits for Hydroxyzine HClmay 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for budesonide inhalation suspension.You asked the Plan to pre-approvethe tier exception. The Plan denied your request. The Plan says Part B covered products are not eligible for reduction to a lower copayment.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 20% coinsurance for Medicare Part B prescription drugs. The enrollee has been asked to pay a 20% coinsurance for therequested medication. The drug falls within the Medicare Part B prescription drugs benefit category. This means that this is 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 pre-approve a tier exception for budesonide inhalation suspension.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the LTACH will provide daily physician visits, labs, wound care, and nutrition monitoring.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee is currently undergoing treatment at an acutecare hospital (ACH) following a large stroke. The enrollee was intubated/ventilated upon presentation and received a tracheotomy shortly thereafter. The enrollee is tolerating a t-piece, but it is unclear whether ventilator liberation is expected or decannulation is warranted. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.