Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee's functional level is such that short-term daily skilled therapy would benefit her recovery. The Plan denied your request. The Plan says that the enrollee has been sent home and does not need daily skilled therapy. Continued intermittent therapy in the home would be sufficient.
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 SNF care. Our reviewer says that the requested SNF admission meets Medicare criteria for medical necessity. Our physician reviewer found the enrollee is a 69-year-old woman with a history of hypertension, diabetes, and chronic respiratory failure, who was admitted to the hospital on 5/31/21 for evaluation of a possible stroke. On 6/7/21, the enrollee ambulated 90 feet with a rolling walker. A short-term rehab stay was recommended to address deficits and to allow the enrollee to regain independence before going home. The available clinical documentation supports that skilled therapy services are required on a daily basis in a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (Denosumab) (CPT code J0897), for the
enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says step therapy is not 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 the medication. Our physician reviewer
found the case file does not contain documentation of trial and failure of zoledronic acid or intravenous (IV)
pamidronate. The documentation does not support that zoledronic acid or IV pamidronate 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 medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Xgeva (Denosumab) (CPT code J0897), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy and occupational therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy and occupational therapy. The Plan denied your request. The Plan says the provider you requested is not part of the enrollee's primary care physician's network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy and occupational therapy to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures (D5110, D5120) for the enrollee.

You asked the Plan to pre-approve the dentures. You say that the enrollee has had significant weight loss over the past year, partially due to being unable to chew food well, and having misaligned dentures. The Plan denied your request. The Plan says this is only available once every five years.

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. The Plan covers the dentures when the services are medically necessary and reasonable. 

Dentures were last received on December 22, 2017. This is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve dentures (D5110, D5120) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve chiropractic services. You say that you would like these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network provider 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 chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and routine venipuncture provided by an out-of-network provider on February 27, 2021.
You asked the Plan to pay for the office visit and routine venipuncture. You say that the other doctor would not give you an appointment. You say that you chose this new primary doctor and want this bill paid or show a copayment only. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 the office visit and routine venipuncture provided by an out-of-network provider on February 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen (15) hours per week of rehabilitative services with 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing evaluation (G0162), a skilled nursing visit (G0299), and a physical therapy visit (G0151).
You asked the Plan to pre-approve home health services. You say that you have pain on your groin and backside. You say that as a result it takes you too long to get ready. You say that you move very slow due to your pain. You also say that it would be more convenient to get physical therapy at home. The Plan denied your request. The Plan says there is no evidence of a skilled need in the home. The Plan also says that there is no certified request from your doctor for the requested services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing evaluation (G0162), a skilled nursing visit (G0299), and a physical therapy visit (G0151).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on November 24, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $90 copayment for Emergency care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on November 24, 2020. You have been asked to pay a $90 copayment for the emergency room visit. 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 copayment for the emergency room visit provided on November 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on January 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that there are in-network providers available.
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 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 an x-ray provided on January 25, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of 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 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intravenous infusions, the chemotherapy administrations, and the chemotherapy drugs provided from April 1, 2020, to April 30, 2020.
You asked the Plan to waive the coinsurance for the intravenous infusions, the chemotherapy administrations, and the chemotherapy drugs. You say that you are not getting any credit for the maximum out-of-pocket amount and every copayment is being sent to you. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs at a specialist's office or outpatient hospital. You have been asked to pay $2,027.81 coinsurance for the intravenous infusions, the chemotherapy administrations, and the chemotherapy drugs. The intravenous infusions, the chemotherapy administrations, and the chemotherapy drugs fall within the "Medicare Part B prescription drugs" benefit category. The record shows you have not met your maximum out-of-pocket amount. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
April 6, 2020
Chemotherapy administration
$126.78
20%
$25.36
April 6, 2020
Cetuximab injection
$2,301.25
20%
$460.25
April 13, 2020
Intravenous infusion
$24.76
20%
$4.95
April 13, 2020
Chemotherapy administration
$126.78
20%
$25.36
April 13, 2020
Chemotherapy administration
$126.78
20%
$25.36
April 13, 2020
Chemotherapy administration
$49.52
20%
$9.90
April 13, 2020
Chemotherapy administration
$24.76
20%
$4.95
April 13, 2020
Cetuximab injection
$2,301.25
20%
$460.25
April 20, 2020
Chemotherapy administration
$126.78
20%
$25.36
April 20, 2020
Cetuximab injection
$2,301.25
20%
$460.25
April 27, 2020
Intravenous infusion
$24.76
20%
$4.95
April 27, 2020
Chemotherapy administration
$126.78
20%
$25.36
April 27, 2020
Chemotherapy administration
$126.78
20%
$25.36
April 27, 2020
Chemotherapy administration
$24.76
20%
$4.95
April 27, 2020
Chemotherapy administration
$24.76
20%
$4.95
April 27, 2020
Cetuximab injection
$2,301.25
20%
$460.25
Total
$2,027.81
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 the intravenous infusions, the chemotherapy administrations, and the chemotherapy drugs provided from April 1, 2020, to April 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the medication is 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 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 Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Nivolumab is not FDA approved for the treatment of adrenal carcinoma and use is not supported by major drug compendia or the medical literatures. The enrollee has progressed on prior immunotherapy with pembrolizumab and additionally treatment with nivolumab would not be indicated alone or with ipilumumab. The service 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair ramp with gradual slope and rails (K0108).
You asked the Plan to pre-approve wheelchair ramp with gradual slope and rails. You say that you are having surgery that will have you bounded to your wheelchair. You will not be able to walk for several months, and your home entrance is not wheelchair safe and will require a temporary ramp to go in and out of your home. The Plan denied your request. The Plan says a fixed, modular or in any way attached ramp is considered a non-portable ramp and is not a Medical benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve wheelchair ramp with gradual slope and rails (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1110, D0150) received February 5,
2021.

You asked the Plan to pay for the dental services (D1110, D0150). You say that the provider you received the
services from is in-network, however the claim was billed with an out-of-network provider. The Plan denied
your request. The Plan says the claim must be processed as it was billed by the provider. Based on the currently
submitted claim, the services were received out-of-network. The Plan has attempted to contact the provider's
office but has not been able to reach any office staff.

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 not
among those covered under this benefit. Services billed as out-of-network are not covered by the Plan.
Therefore, we decided that the Plan does not have to pay for the dental services (D1110, D0150) received
February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that it is felt that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says the member must require multitherapy interventions with documentation of the expectation of reasonable improvement. In addition, there must be an ongoing requirement for medical supervision. This is not documented.
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 the patient was admitted for subdural hematoma and subarachnoid hemorrhage after a fall. Medical conditions 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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. 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.