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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting. 
 
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. The short-
term acute care hospital can provide for all the patient's present inpatient care needs and the patient is receiving 
an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is 
appropriate until the patient is stable to transfer to a lower level of care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on March 2, 
2020. 
 
You asked the Plan to reduce the coinsurance for the Part B injection. You say that your payment went from 
$327 in previous years to $437.  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 20% 
coinsurance for Part B drugs that are administered by a provider.  
 
You have been asked to pay $436.68 which is 20% of the allowed amount for the Part B injection. The allowed 
amount is $2,183.40. ($2,183.40 x 20% = $436.68). The Part B injection falls within the ?Medicare Part B 
prescription drugs? 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 coinsurance for the Part B injection 
provided on March 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve physical therapy. You say that the enrollee has been making good progress
in his mobility with therapy. The Plan denied your request. The Plan says the enrollee has been able to maintain
his ability using a home program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 physical therapy. Our physician
reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the
patient's condition. The enrollee has a had prior therapy for this condition. His current functional level does not
require the unique skills of a professional therapist to safely and effectively provide treatment. The services do
not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. He
has had extensive therapy and should be able to transition to an independent home exercise program. The
requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of
a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's
current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider from May 20, 2019, to September 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
from May 20, 2019, to September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee has 
not met the step therapy requirements. 
 
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 Synvisc-One. Our reviewer says that 
the enrollee has not met the step therapy requirements for coverage of the requested drug. Our physician 
reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. 
Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell transplantation for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says multiple rounds of autologous stem cell transplantation for patients with multiple 
myeloma is not considered medically reasonable and necessary, and is not covered by Medicare. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found multiple rounds of transplant are not covered, per the MCD. The enrollee has had two previous 
autologous transplants. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stem cell transplantation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower bench. 
 
You asked the Plan to pre-approve a shower bench. You say that you have developed a pressure ulcer and you 
have several more months of treatment for it. You say that using other benches or chairs does nothing to help 
with the healing of your wound. You stated that you have considerable pain with your wound, and you believe 
that should be enough justification for the Plan to approve coverage of the requested equipment. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower bench 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 pre-approve a shower bench.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 30, 2019 
through January 2, 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 patient with multiple severe comorbid conditions presents with dyspnea and possible need for 
thoracentesis. Regardless, the patient has significant enough acute worsening and chronic conditions that it 
would be reasonable to expect that greater than two midnights would be required for this hospital stay. 
 
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 December 30, 2019 through January 2, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxycodone-acetaminophen.
You asked the Plan to pre-approve oxycodone-acetaminophen. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve oxycodone-acetaminophen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a mandibular partial 
denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that 
you are unable to use the dentures you currently have. The Plan denied your request. The Plan says you have 
exhausted your denture benefit. 
 
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, dentures are covered once per arch 
every 5 years. The record shows that you received a maxillary partial denture and a mandibular partial denture 
on December 23, 2016 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a complete maxillary denture and a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that your primary care physician has not 
performed any tests to figure out where your pain is coming from. The Plan denied your request. The Plan says 
there are in-network providers available for these services. 
 
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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services (74018) provided on February 20, 2020. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the submitted claims are duplicates of an 
already paid claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the medical records document that there were 3 radiology services 
provided at 3 different times of the day with different results for each service. We find that the Plan has not 
substantiated their denial of payment in that the claims are not considered duplicates per Medicare guidelines. 
Therefore, we decided that the Plan has to pay for the radiology services (74018) provided on February 20, 
2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay and the emergency room visit provided from February 28, 2020 to May 1, 2020.
You asked the Plan to waive the copayments for the inpatient hospital stay. You say that you should have no member liability. 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 $75 copayment per day, days 1-4 for an in-network inpatient hospital stay and a $0 copayment per day, days 5 to 90 for an in-network inpatient hospital and a $120 copayment for emergency services at an in-network emergency room. You have been asked to pay a $300 copayment for the inpatient hospital stay. ($75 x 4 days = $300). You have also been asked to pay a $120 copayment for the emergency room visit. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The emergency room visit falls within the "Emergency 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 copayments for the inpatient hospital stay and the emergency room visit provided from February 28, 2020 to May 1, 2020.
Your complaint about not receiving adequate care 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital breast tomosynthesis services provided on July 12, 
2019 billed with code 77062. 
 
You asked the Plan to pay for the testing as billed. You say that the records show this was performed and 
necessary. The Plan denied your request. The Plan says the code used to report this testing is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
CPT code 77062 has a status indicator of "I" in the Medicare Physician Fee Schedule, meaning it is invalid for 
Medicare billing purposes. The correct code for this testing is G0279. Therefore, we decided that the Plan does 
not have to pay for the digital breast tomosynthesis services provided on July 12, 2019 billed with code 77062.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July
10, 2019.
You asked the Plan to pay for the drug testing. You say that this testing is medically necessary. The Plan
denied your request. The Plan says the order provided is not signed by the treating provider and no records
were submitted to support the intent for this to be performed.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the
treating provider. Though an order need not be signed, the records must support the intent that the test be
performed.
In this case, the order form provided is unsigned and there are no medical records provided showing the intent
for this testing. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive
drug testing provided on July 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the provider did not show a reason why the enrollee needs to be on a breathing
machine 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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have
complex wound care or other ongoing SNF level SN need. Her functional level does not require skilled therapy
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively
provide medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this
enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.