Persius/hicric huggingface dataset:
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 services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. In this case, ongoing care needs include intravenous antibiotics, surveillance laboratory studies with indicated hemodialysis, sacral wound care, glucose control, and therapy services. 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 he 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. 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4550) provided to the enrollee on August 2, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in payment for the nerve blocks.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code A4550is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service.Therefore, we decided that the Plan does not have to pay for the services (A4550) provided to the enrollee on August 2, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).
You asked the Plan to pre-approve a knee scooter. You say that a scooter will provide more support. The Plan
denied your request. The Plan says that this s not considered by the Medicare DME MAC to be medically
reasonable or necessary for any indication.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch
substitutes (E0118).
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical
equipment in the State of California has decided that the knee scooter coded as E0118 is not medically
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a knee
scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter
(E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (90215) provided September 30, 2019.
You asked the Plan to pay for the refraction services. You say that you are requesting coverage and payment based on the benefits. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when routine eye examinations is covered once a year. Per the records refraction services was provided on April 23, 2019. We looked at the file and the Plan's rules. the eye refraction service is not covered because the enrollee already received this service on April 23, 2019. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services (90215) provided September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3D image rendering of the brain MRI without contrast.You asked the Plan to pre-approvethe 3D imaging services. You say that a 3D rendering of the enrollee's MRI is medically indicated and necessary to support or refute the possibility that Alzheimer's disease dementia is the cause of her cognitive decline.The Plan denied your request. The Plan says therecords provided do not show the reason that the 3D processing is needed or why the approved MRI would not be good enough for imaging the enrollee's condition.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 3D imaging services. Our reviewer says that 3D imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is undergoing evaluation for a cognitive complaint and there is suspicion of possible Alzheimer's Disease. Our physician reviewer found that the use of biomarkers is not readily supported because the core clinical criteria provide very good diagnostic accuracy and utility in most patientsand because more research needs to be done to ensure that criteria which include the use of biomarkers have been appropriate designed. In addition, there is a limited standardization of biomarkers from one locale to another and access to biomarkers I limited to varying degrees in community settings. For this reason, it cannot be said that 3D imaging would not be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member. In addition, the 3D imaging may be one that exceeds the enrollee's clinical need to establish a diagnosis for her conditioning. Our physician reviewer found that the guidelines recommend reserving he use of various biomarkers for investigational studies and clinical trials.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 3D imaging services have not been met.Therefore, wedecided that the Plan does not have to pre-approve3D image rendering of the brain MRI without contrast.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiogram (MRA) of the neck 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. Medicare rules say that MRA is covered for specific indications only. 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 submitted records contain no evidence of neurologic signs or symptoms for which an MRA would be appropriate. A recent carotid ultrasound demonstrated no clinically significant stenosis. The requested MRA of the neck is not reasonable or medically necessary. 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 magnetic resonance angiogram (MRA) of the neck for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance Part B drugs received on May 13, 2019 and June 12, 2019.You asked the Plan to waive the coinsurance the services. You say that there should be a responsibility of a $105 copayment.The Plan denied your request. The Plan says the claim was processed appropriately according the benefits and the services rendered.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 19% coinsurance for Medicare Part B drugs. You have been asked to pay 19% coinsurance for the services.The services fall within the Medicare Part B 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 waive the coinsurance Part B drugs received on May 13, 2019 and June 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses purchased on July 15, 2019.You asked the Plan to pay for the frames and lenses. You say that you request review of the records. You needed new glasses and feel that the claim was denied in error.The Plan denied your request. The Plan says the claim was processed correctly and the correct cost share had been applied.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says you must pay any amount over $100 towards the purchase of eyeglasses (frames and lenses)  for Vision care.You have been asked to pay 231.36. The provider billed $357.98. You must pay any amount over $100. for the frames and lenses. the frames and lenses falls within the Vision 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 pay for the frames and lenses purchased on July 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) monitoring device (A9279) provided July 31, 2019 to August 31, 2019.
You asked the Plan to pay for CPAP monitoring device. You say that the services were medically necessary and should be reconsidered. 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 monitoring devices (integrated or modular) are capable of tracking data generated by a RAD or PAP device, which can be subsequently downloaded for further analysis by a healthcare provider, DME supplier, or beneficiary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPAP monitoring device have not been met. Therefore, we decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) monitoring device (A9279) provided July 31, 2019 to August 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One injection services.You asked the Plan to pre-approvethe Synvisc-One injection services. You say that the records provided support the medical necessity of the requested drug. You say that you do not stock the preferred drugs in the office.The Plan denied your request. The Plan says the information submitted does not meet the medical necessity guidelines for coverage.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 Synvisc-One injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requiresthese be trialed first. The documentation does 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 the Synvisc-One injection services have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One injection services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveReliOn Premier test strips.You asked the Plan to pre-approvethe non-preferred test strips. You say that the enrollee cannot afford a new meter so the enrollee needs the ReliOn Premier test strips.The Plan denied your request. The Plan says there is no medical reason the enrollee has to use the non-preferred brand of test strips.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The documentation does not show that it is medically necessary to use the non-preferred brand of test strips. Based on this information, we decided that Medicare rules for coverage of the non-preferred test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveReliOn Premier test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNeupro 4 mg/24 hr patch.You asked the Plan to pre-approveNeupro 4 mg/24 hr patch. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does notinclude Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveNeupro 4 mg/24 hr patch.Benefits for Neupro 4 mg/24 hr patchmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from October 12, 2017 through October 17, 2017.You asked the Plan to pay foracute 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 aremet in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from October 12, 2017 through October 17, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided October 28, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that you were not at the lab facility on the date of service. 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). The enrollee's contract with the Plan clearly says that enrollees must pay an $8 copayment for bloodwork drawn at a physician's office and sent to an independent lab for processing. The enrollee has been asked to pay an $8 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the lab work was processed at an independent lab.This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe laboratory work provided on October 28, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe debridement services provided from July 30, 2019 to August 28, 2019.You asked the Plan to waive the copayment forthe debridement services. You say that you are appealing this charges.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 $395 copayment for each Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $395 copayment for debridement services in an outpatient hospital.You have been asked to pay a $277.50 copayment for each date of service for the debridement services. The debridement services fall within the "Outpatient Surgery and Other Medical Services Provided at HospitalOutpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe debridement services provided from July 30, 2019 to August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the 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 theyare 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 is currently undergoing treatment at an acute care hospital (ACH) for sepsis related to multiple chronic wounds. The enrollee is tracheotomy, ventilator, feeding tube and hemodialysis dependent at baseline. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs (tracheotomy care,ventilator management, tube feed administration, hemodialysis).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (CPT Code E1390RR) provided on September 10, 2019, by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an oxygen concentrator (CPT Code E1390RR) provided on September 10, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 coinsurance for oxygen concentrator (CPT Code E1390RR) provided on September 10, 2019, by an in-network provider.