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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the care needed is custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the 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, new enteral feedings, complex wound care or other SNF level skilled nursing need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF.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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on November 8, 2019.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should be charged a $40 copayment and not a $50 copayment. You say you have been going that office for years and have never paid that much. 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 $50 copayment for each out-of-network specialist office visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for a specialist office visit.
You have been asked to pay a $46.67 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the specialist office visit provided on November 8, 2019.
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 December 9, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told you did not owe a copayment and you say the provider did not give you an examination. 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 $40 copayment for each specialist visit for Medicare-covered benefits (including telehealth services). You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, including Doctor's Office Visits" benefit category. The medical record shows the physical exam was refused, but that the current medication treatment will continue.
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 December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 30, 2019 to October 31, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated at a lower level of care.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. The enrollee presented to the emergency department complaining of chest pain. Evaluation revealed atrial fibrillation with a rapid ventricular response. He was placed on Lovenox and admitted. The following day he underwent a cardiac catheterization. No intervention was required. He tolerated the procedure and was monitored. He was discharged home with outpatient follow-up.
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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 30, 2019 to October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that your provider wants to avoid long-acting Reclast. The Plan denied your request. The Plan says the requested use of Prolia is not a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Prolia. Our reviewer says that the use of Prolia is not supported in this case. Our physician reviewer found Prolia use in Paget's disease is limited to case reports in the medical literature. While the use of this medication in this clinical situation may have some pathophysiologic basis and rationale, it does not meet the criteria of being supported by drug compendia or research evaluating its use in CMS-approved journals. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular urine panel provided on December 13, 2019.
You asked the Plan to pay for lab testing. You say that this testing is not experimental/investigational and is covered by Medicare. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this testing remains unproven in peer-reviewed medical literature and a bacterial urine culture, which is the standard of care, was not performed.
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 pay for lab testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no records of a provider evaluation explaining why this testing was ordered. There is no documentation as to why an initial urine dip or standard urine culture and sensitivity would not have been sufficient to diagnose and manage the enrollee's health. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular urine panel provided on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CardioMEMS is not covered unless the enrollee is in a clinical trial. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is in an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intron A eye drops for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Intron A eye drops for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 8, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the dental services should be paid. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 provider is not in-network and your EOC clearly states, services obtained from vendors outside this network are not covered. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 8, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 13, 2019by an out of network provider.You asked the Plan to pay forthe out-of-network medical services. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not request 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 ofarea urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 forthe medical services provided on September 13, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forthe observation discharge management provided on December 20, 2019.You asked the Plan to waive the copayment forthe observation discharge management. You say that you have no recollection of a visit from the doctor. You say that you shouldn't be financially responsible.The Plan denied your request. The Plan says that the copayment applied correctly.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 $0 copayment for each primary care physician visit for a Medicare-covered service. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any The Plan says you must pay a $45 copayment for the observation discharge management. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the observation discharge management. The records show that the doctoris a family medicine provider.Therefore, we decided that the Plan has to waive the copayment forthe observation discharge management provided on December 20, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Xifaxan 550 mg tablet medication (J8499).
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the enrollee has a medical (MA) only policy with the plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xifaxan 550 mg tablet medication (J8499).
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for home delivered meals.
You asked the Plan to provide coverage for the home delivered meals. You say that you have severe neuropathy of your extremities, especially in your feet, due to diabetes and it is difficult for you to stand for a long period of time to cook your meals. The Plan denied your request. The Plan says you do not meet the Plan's supplemental benefit criteria for the meal program.
The contract with the Plan says that the meals program is a supplemental benefit after the enrollee is discharged from an inpatient stay at a hospital or a nursing facility. We looked at the file and the Plan's rules. The file shows that you have not been discharged from an inpatient stay at a hospital or a nursing facility. Based on this information, we decided that the Plan's rules for coverage of the home meals program have not been met. Therefore, we decided that the Plan does not have to provide coverage for home delivered meals.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on August 14, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that the claim should be paid. The Plan denied your request. The Plan says payment for this claim was made by the enrollee's auto insurance carrier; therefore, the healthcare plan will not duplicate payment.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Payment is calculated taking into consideration the payment made by the auto insurance carrier and Medicare's allowable amount. Combined, the auto insurance carrier payment and the Plan's payment should not exceed our normal allowable amount. The auto insurance carrier paid $610.52 therefore, the Plan's responsibility was $0.00. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 29, 2019 to November 1, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on October 29, 2019 with left lower quadrant abdominal pain. The evaluation revealed an abnormal urinalysis, normal WBC, normal renal function, normal CXR and a normal CT of the abdomen/pelvis. The enrollee was diagnosed with pyelonephritis and started on IV antibiotics and IV fluids. The enrollee was admitted. The enrollee's condition stabilized and improved and the enrollee was discharged home on November 1, 2019 when considered medically stable. The documentation shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 for the acute inpatient hospital care provided from October 29, 2019 to November 1, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulmonary testing (94618, 94375, 94729, 94727) provided on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON pulmonary testing. You say that these services were medically necessary. 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 provider at issue in this case is not a network provider with the Plan. 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 OON pulmonary testing. Our reviewer says that the criteria for coverage of these services have not been met. Our physician reviewer found the documentation shows that the provider is not contracted by the plan, there was no prior authorization request, no referral from the enrollee's primary care physician, and no evidence of an emergency room admission. Given the documentation provided for review, the services at issue in this case were not medically reasonable, necessary and emergent in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OON pulmonary testing have not been met. 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 pay for OON pulmonary testing. Therefore, we decided that the Plan does not have to pay for the pulmonary testing (94618, 94375, 94729, 94727) provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day system.
You asked the Plan to pre-approve a Freestyle Libre 14-day system. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Medicare states a CGM is covered if criteria above are met. Medicare states you must be insulin treated in order to meet criteria for a CGM. The file shows you are not insulin treated and do not meet criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day system.