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.
You asked the Plan to pre-approve IRF care. 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 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that you would like reconsideration because the member has failed trial of oral iron supplementation and receives IV iron as needed. The Plan denied your request. The Plan says this drug is not medically necessary.
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 Aranesp. Our reviewer says that the requested use of Aranesp is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found its use 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 30, 2020.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on September 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on October 10, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have any copayment for the transfer because of COVID-19. The Plan denied your request. The Plan says you were charged this cost sharing 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 $222 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $222 for these services. This Plan did not have Coronavirus ambulance copayment waivers. 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 ambulance services provided on October 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility admission.
You asked the Plan to pre-approve the Skilled Nursing Facility admission. You say that you would like
reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan
says the member's needs may be met in a lower level of care.
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 the Skilled Nursing Facility admission.
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does
not meet severity of illness or intensity of service criteria for 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 Skilled Nursing Facility admission have not been met. Therefore, we
decided that the Plan does not have to pre-approve Skilled Nursing Facility admission.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an emergency room visit provided by a participating provider on October 25, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you thought that if you were admitted then the emergency room visit copayment would be waived. The Plan denied your request. The Plan says that the correct copayment has been applied.
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 enrollees must pay a $50 copayment for emergency care. The Plan says you must pay a $50 copayment for an emergency room visit. Based on the Plan contract, however, if you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Therefore, we decided that the Plan has to waive the copayment for an emergency room visit provided by a participating provider on October 25, 2020 due to being admitted to the hospital.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to hold you harmless for the manual therapy techniques (97140) and therapeutic
exercises (97110) provided on December 10, 2020.
You asked the Plan to hold you harmless for the manual therapy techniques and therapeutic exercises. You say
that you would like reconsideration because you were referred for these services by your provider. The Plan
denied your request. The Plan says that a modifier was not billed on the claim to represent the services as
separate/distinct.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the manual therapy techniques and therapeutic exercises by a contract provider. The file
does not show that the Plan provided notice that the manual therapy techniques and therapeutic exercises would
not be covered. Additionally, the record shows that you paid out-of-pocket for these services and would not be
aware that a modifier would be necessary to bill these services. Under Medicare rules, this means the manual
therapy techniques and therapeutic exercises is considered approved by the Plan. Therefore, we decided that the
Plan has to hold you harmless for the manual therapy techniques (97140) and therapeutic exercises (97110)
provided on December 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture, withdrawal of arterial blood, chest x-ray, laboratory services, ECG, airway inhalation treatment, therapeutic, prophylactic, or diagnostic injection, ED visit, and Furosemide injection provided on October 21, 2020.
You asked the Plan to pay for the routine venipuncture, withdrawal of arterial blood, chest x-ray, laboratory services, ECG, airway inhalation treatment, therapeutic, prophylactic, or diagnostic injection, ED visit, and Furosemide injection. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the routine venipuncture, withdrawal of arterial blood, chest x-ray, laboratory services, ECG, airway inhalation treatment, therapeutic, prophylactic, or diagnostic injection, ED visit, and Furosemide injection provided on October 21, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that this drug is not medically necessary and reasonable. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees whose provider has requested Gel-One for their condition. In this case, the patient has not tried and failed the required drugs Orthovisc and Monovisc. In addition, the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 (J7326).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, thorax, low dose for lung cancer screening, without contrast material(s) (CPT code 71271).
You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan denied your request. The Plan says that the Medicare rules have not been met.
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 CT scan. Our physician reviewer found based on the medical records provided, you meet the requirements for a LDCT of the thorax or chest. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve CT, thorax, low dose for lung cancer screening, without contrast material(s) (CPT code 71271).
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 inpatient rehabilitation is the clear most appropriate level of care to achieve the best possible outcome for this patient and achieve highest level of independent function and quality of life as quickly as possible. 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 replacement of an implanted defibrillator. 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: 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 you would like reconsideration because you need
assistance with activities like getting into bed and lifting your leg. The Plan denied your request. The Plan says
based on your records, you have reached a custodial 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 there are no complex nursing or rehabilitation needs. Medically necessary care can be
provided in a different 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950 x2), and the crowns - porcelain/ceramic (D2740 x2) received December 21, 2020.
You asked the Plan to pay for the core buildup and the crowns. You say that the Plan failed to correctly calculate the in-network rates for the provider. The Plan denied your request. The Plan says the correct cost share has applied to the claim.
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, the requested items or services are either not among those covered under this benefit or in excess of those covered by this benefit. The Plan does not cover core buildup. In addition, the Plan requires a 70% coinsurance for up to two crowns per year. The Plan's allowed amount for the crowns was $881, and you were assessed 70% coinsurance ($616.70 x2) for the crowns. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950 x2), or pay an additional amount for the crowns - porcelain/ceramic (D2740 x2) received December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220) provided on December 15, 2020.
You asked the Plan to pay for the dental services. You say that this appointment was for an infection that needed to be treated. You also say that this was not for a routine check-up. The Plan denied your request. The Plan says there is a maximum benefit of $500 for covered dental services. The Plan also says that the maximum benefit has been exhausted.
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, the annual maximum benefit of $500 has been exhausted prior to the date of service in this case. The Evidence of Coverage clearly states that you are responsible for any cost above the $500 maximum. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the initial periapical x-ray (D0220) provided on December 15, 2020.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve the carotid duplex. We decided that the Plan does not have to preapprove
magnetic resonance angiography.
You asked the Plan to pre-approve the carotid duplex. You say that you would like reconsideration because the
requested services are medically necessary. The Plan says that the carotid doppler is being requested to
investigate the member's dizziness.
We decided that the Plan has to pre-approve the carotid duplex.
The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies are medically necessary
only if the outcome will potentially impact the clinical management of the patient. Services are deemed
medically necessary when specific conditions are met. 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 carotid duplex. Our reviewer says
that there is satisfactory documentation of extensive cardiovascular risk factors. This is an indication for carotid
duplex and meets LCD criteria.
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 carotid duplex have been met. Therefore, we decided that the Plan has to
pre-approve the carotid duplex.
We also decided that the Plan does not have to pre-approve magnetic resonance angiography.
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for
any item or service, the information submitted by the supplier or provider must corroborate the documentation
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
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 magnetic resonance angiography. Our
physician reviewer found there is insufficient documentation to support the magnetic resonance angiography.
Apparently, this request originated from a neurologist, but the supporting documentation is not provided. The
progress notes provided do not include an assessment of the member's symptoms or rationale for requesting
this study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of magnetic resonance angiography have not been met. Therefore, we decided that
the Plan does not have to pre-approve magnetic resonance angiography.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mental health care you received on July 3, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the 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). Your contract with the Plan clearly says that you must pay a $35 copayment per day for Medicare-covered partial hospitalization services. Review of the file shows that you were provided partial hospitalization services on July 3, 2020. You have been asked to pay a $35 copayment for the services. The services fall within the partial hospitalization services 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 mental health care you received on July 3, 2020.