Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210 x 5), the alveoloplastyin conjunction with extractions (D7310 x 2), the extraction of an erupted tooth root (D7140 x 3), general anesthesia, initial 15 minutes (D9222), and the general anesthesia, additional 15 minutes (D9223) provided on June 3, 2019.You asked the Plan to pay forthe dental services. You say that the dental services were necessary to prevent damage to your heart valves.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services received out of network are not covered.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 dental services you received are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 5), the alveoloplasty in conjunction with extractions (D7310 x 2), the extraction of an erupted tooth root (D7140 x 3), general anesthesia, initial 15 minutes (D9222), and the general anesthesia, additional 15 minutes (D9223) provided on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that this provider is the only specialist that works at the nursing home. The Plan denied your request. The Plan says these 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 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 for nursing facility care (99308) provided on September 4, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided July 31,
2019 to August 24, 2019.
You asked the Plan to pay for the SNF services. You say that SNF services were medically necessary. The Plan
denied your request. The Plan says services could have been provided at 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 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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there were no noted daily skilled
complex nursing needs. The records do not support the need for daily therapy or daily skilled nursing 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for Skilled Nursing Facility (SNF) services provided July 31, 2019 to August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided on January 10, 2019 to April 18, 2019
by an out of network (OON) provider.
You asked the Plan to pay for office visits. You say that you are returning to the same doctor who did your
initial surgery. You say that this is ideal. The Plan denied your request. The Plan says no prior authorization
was obtained for these office visits.
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 for office visits provided on January 10, 2019 to April
18, 2019 by an out of network (OON) provider.
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
September 18, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for 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 $70
copayment for services obtained from an out-of-network specialist.
You have been asked to pay a $70 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 specialist office visit provided on September 18, 2019.
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 these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 20, 2020 and was diagnosed with hypoxic respiratory failure and was intubated. He has had a tracheostomy and PEG tube placement. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. The documentation does not support that the enrollee is likely to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on July 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forhome health services. You say that you are the only other House Call Group in the Houston area.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 theseitems/services.Therefore, we decided that the Plan does not have to pay forhome health services provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 8, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid authorization for this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 servicesat 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 physician's services provided on July 8, 2019.
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 enrollee can handle an intensive program and would benefit from acute medical care during his program in order to monitor her fluid levels. The Plan denied your request. The Plan says the enrollee does not require the level of rehab in the IRF or frequent physician oversight.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to the hospital on 2/4/2020 after being discharged after total hip replacement. She presented with hip pain and was found to have a acute femur fracture. She is currently receiving non-surgical care for this. 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 documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient's functional level does not require this on an intensive rehabilitation facility therapy program level 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 Eylea (J0178) for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy guidelines were not followed.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of the required drug. The medical record does not indicate that Bevacizumab 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 the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Eylea (J0178) for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 11, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 subsequent nursing facility care provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of care (such as a skilled nursing facility, or acute inpatient rehabilitation), or until the clinical circumstances change such that LTACH may be reconsidered.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the level of care standards for transfer to LTACH to be appropriate at this time. Ventilatory status does not meet criteria and the enrollee does not have any other needs that would make transfer to LTACH indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires daily skilled nurse monitoring due to change is psychiatric medication. She would also benefit from one hour of daily therapy. The Plan denied your request. The Plan says the enrollee's needs can be met with less than daily skilled services.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurolane for the enrollee.You asked the Plan to pre-approveDurolane. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 Durolane. Our physician reviewer found that the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs.  The documentation does not support that Orthovisc and Monovisc would likely be less effective, 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 Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve surgery to remove excess skin from the abdomen (15830).
You asked the Plan to pre-approve surgery to remove excess skin from the abdomen (15830). You say that the requested surgery to remove excess skin from the abdomen is medically necessary. The Plan denied your request. The Plan says that the requested surgery to remove excess skin from the abdomen is not medically necessary.
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, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. In this case, the file shows that the provider had taken photographs on December 18, 2019 during a consultation. We sent the Plan a request for these photographs as they were not included in the case file sent by the Plan. The Plan responded and provided the same documentation that was in the original case file and provided no photographs and no explanation. Therefore, we decided that the Plan has to pre-approve surgery to remove excess skin from the abdomen (15830).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you need further assistance. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were hospitalized from January 29, 2020 to February 5, 2020 with gallstones and underwent surgery. You had stable vital signs and completed a course of antibiotics. You received physical and occupational therapy in the hospital and need assistance with walking 160 feet with a rolling walker. You need varied levels of assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not need skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.