Persius/hicric huggingface dataset:
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of an ankle fracture after a fall and for a pulmonary embolism. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and hand finger orthosis provided on December 15, 2020.

You asked the Plan to pay for the knee orthosis (L1833) and hand finger orthosis (L3930). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no proof of delivery for the orthoses.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The record does not contain a valid physician order or medical records supporting the hand finger orthosis. There are no proof of delivery documents in the case file. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis and hand finger orthosis provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Prodigy blood glucose test strips (A4253), Prodigy calibrator solution or chips (A4253), and Sterilance lancets (A4259) provided on July 30, 2020.

You asked the Plan to pay for Prodigy blood glucose test strips, Prodigy calibrator solution or chips, and Sterilance lancets. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for the requested items have not been met.

The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those
preferred brands and manufacturers.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prodigy blood glucose test strips, Prodigy calibrator solution or chips, and Sterilance lancets have not been met. Specifically, the requested items are not made by OneTouch/Lifescan. Therefore, we decided that the Plan does not have to pay for Prodigy blood glucose test strips (A4253), Prodigy calibrator solution or chips (A4253), and Sterilance lancets (A4259) provided on July 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One 30 MG/3 ML syringe.

You asked the Plan to pre-approve Gel-One. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the use of this drug for the member's condition is experimental.

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 Gel-One. Our reviewer says that the requested use of Gel-One is not FDA-approved for the enrollee's diagnosis. Gel-One 30 MG/3 ML syringe is FDA approved only for knee osteoarthritis. Our physician reviewer found the use of Gel-One for the treatment of osteoarthritis of the shoulder is not supported by one of the major drug compendia or by clinical research that appears in a CMS approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One 30 MG/3 ML syringe.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from November 13, 2020 to November 23, 2020.

You asked the Plan to waive the copayment for these services. You say that you do not understand why you have to pay again. 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 $625 copayment per day for days 1-3 for in-network inpatient hospital care.

Review of the file shows that you received inpatient hospital services from November 13, 2020 to November 23, 2020. You have been asked to pay a $625 copayment per day for days 1-3 for these services, for a total of $1,875. These services fall within the in-network 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 hospital services rendered from November 13, 2020 to November 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 23, 2020,
to March 23, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claims were billed incorrectly.

The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes,
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the
three Q codes.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a required G code in
addition to the billed Q code. 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 pay for the home health
services rendered from February 23, 2020, to March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ear wax removal provided on January 11, 2021.

You asked the Plan to waive the deductible for the ear wax removal. You say that the procedure took less than one minute and produced a small amount of wax. You say that the charge is excessive, and you want it eliminated. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. 

The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to additional services received during an office visit. This cost sharing is a contractual obligation that had not been met at the time the ear wax removal was received on January 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ear wax removal provided on January 11, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not meet complexity of nursing, medical management, and rehabilitation requiring an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of degenerative joint disease, peripheral vascular disease, COPD, and pressure ulcers of sacrum and buttocks and are living at home with increasing weakness. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 are no services at the LTACH that the enrollee requires that are not already available and covered 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 when treatment has completed and the enrollee is more stable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a MyoPro 2 Motion G orthotic device to be provided by an OON provider. You say that the item is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this item. Therefore, coverage criteria have not been met.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on August 3, 2020 and August 17, 2020.

You asked the Plan to waive the copayment for the cataract surgery. You say that you have already reached your maximum and the practitioners should be billing the insurance directly. You say that you are entitled to a rebate. The Plan denied your request. The Plan says the copayments 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $295 copayment for each cataract surgery. The total amount you owe is $590 ($295/surgery x 2 surgeries = $590). The cataract surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show your maximum out-of-pocket was not met prior to the surgeries. 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 cataract surgery provided on August 3, 2020 and August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 are no services at the LTACH that you require that are not already available and covered 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 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the SPECT test provided on February 4, 2021.
You asked the Plan to reduce the copayment for the SPECT test. You say that you thought you would have a $10 copayment like you had in the past for previous stress tests. 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 $150 copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests). You have been asked to pay a $150 copayment for the SPECT test. The SPECT test 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 reduce the copayment for the SPECT test provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lymph system imaging provided on December 17, 2020.

You asked the Plan to waive the copayment for the lymph system imaging. You say that the diagnostic procedure was moved which required you to go to the hospital twice. You say that this should be considered part of your surgery. 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay a $160 copayment for the lymph system imaging. The lymph system imaging falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The lymph system imaging is considered a separate service. 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 lymph system imaging provided on December 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.

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 Euflexxa. Our reviewer says that the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The medical documentation does not show that the member has tried and failed Orthovisc and Monovisc. Our physician reviewer found the medical documentation does not show that the Plan's required drugs would likely be less effective or have adverse effects for the member. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 7.

You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.

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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 7.