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

We decided that the Plan does not have to pre-approve Spravato.
You asked the Plan to pre-approve Spravato. You say that the enrollee is stable on this medication and needs to continue. The Plan denied your request. The Plan says this drug should be covered under Part D.
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 Spravato. Our reviewer says that Spravato is not medically necessary at this time. Our physician reviewer found Spravato is considered an adjunct for the treatment of treatment resistance Major Depressive Disorder. Based on review of the records provided, it does not appear that this patient is not meet the criteria for the use of Spravato as this would be considered investigational/experimental for the use in the treatment of Bipolar Disorder and Posttraumatic Stress Disorder. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Spravato have not been met. Therefore, we decided that the Plan does not have to pre-approve Spravato.
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 the enrollee has too many medical complications at this time for a lower level of care and needs LTACH service. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 as LTACHs and acute care hospitals 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 acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: 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 that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator system (E0431, E0443, and E1390).
You asked the Plan to pre-approve a portable oxygen concentrator system. You say that you need oxygen 24 hours a day. The Plan denied your request. The Plan says these items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that home oxygen therapy is covered when the beneficiary's blood gas study meets the criteria stated above. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator system have not been met. Specifically, there were no medical records submitted that show your arterial PO 2 or arterial oxygen saturation is in the ranges listed above. Without this information, medical necessity cannot be established. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator system (E0431, E0443, and E1390).
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 October 14, 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 for the physician's assistant because on the following visit, your doctor said there were no signs of infection. 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 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 you were examined during the office visit.
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 October 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 28, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that the ultrasound should be covered as a mammogram screening. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $10 copayment for each basic imaging service. You received an ultrasound on October 28, 2019. Ultrasounds are not part of a mammogram screening. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound provided on October 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you started having cold sweats and it was believed that you may be having a heart attack. An ambulance was called for you and when they arrived they treated and evaluated you. You say that you began to feel better and your vitals were okay so you felt that you did not need to go to the hospital. You say that you believe the Plan should cover the services because it was an emergency. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 15, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (code D4212), porcelain or ceramic crown (code D2740), and core buildup, including any pins when required (code D2950) provided on April 5, 2019.
You asked the Plan to pay for the gingivectomy or gingivoplasty, crown, and core buildup. You say that at your first appointment the dentist assured you that his staff would contact your plan to get the exact cost of your treatment. You also say that your dentist confirmed on the date of these services that you would only owe $311.20. The Plan denied your request. The Plan says these services are not covered because they are not on the list of covered dental services.
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. Therefore, we decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (code D4212), porcelain or ceramic crown (code D2740), and core buildup, including any pins when required (code D2950) provided on April 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203), manual therapy (97140),
and electrical stimulation (97014) provided on September 27, 2019.
You asked the Plan to pay for a chiropractic office visit, manual therapy, and electrical stimulation. You say
that you were told these services were covered. The Plan denied your request. The Plan says these services are
not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for a chiropractic office visit (99203), manual therapy (97140), and electrical
stimulation (97014) provided on September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the compression system application provided from September 3, 2019 through September 30, 2019.
You asked the Plan to waive the copayments for the compression system application. You say that you are being charged for visiting the hospital. You say that you should only be charged $10 per visit for the wound care center. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for surgery services at an outpatient hospital. You have been asked to pay a total of $250 for the compression system application. ($50/visit x 5 visits = $250). The compression system application falls within the "Outpatient hospital services" benefit category. The records show that the compression system application was billed by the hospital. 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 copayments for the compression system application provided from September 3, 2019 through September 30, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia 60mg injections.You asked the Plan to pre-approve Prolia. You say that Proliais medically necessary.The Plan denied your request. The Plan says that they failed to make a coverage decision within the allowed timeframe.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 Prolia. Our reviewer says that the Prolia is medically necessary. Our physician reviewer found patients are considered at high risk of fracture if they have a history of osteoporotic fracture, multiple risk factors for fracture, or failed or cannot tolerate other available osteoporosis therapy. The review has determined that the requested Prolia is medically necessary and reasonable for the treatment of the enrollee's osteoporosis.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 been met.Therefore, we decided that the Plan has to pre-approveProlia 60mg injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 19, 2019 to October 1, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There are providers in-network that could render the services at issue.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the physician services provided on September 19, 2019 to October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided from August 1, 2019 through October 29, 2019.
You asked the Plan to waive the copayments for the office visits. You say that an office visit is being charged for a blood draw. You say that prior to these visits she was not being charged. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $20 copayment for each office visit to any PCP type provider. The enrollee has been asked to pay a $20 copayment for each office visit. The total amount the enrollee must pay is $140 ($20/visit x 7 visits = $140). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. 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 copayments for the office visits provided from August 1, 2019 through October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided by July 15, 2019.
You asked the Plan to pay for the orthosis. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided by July 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you have difficulty walking up your stairs. You use a walker and is susceptible to falling. The Plan denied your request. The Plan says this item is a convenience item and is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve weekly skilled nursing visits and 14 hours a week of a home health aide.
You asked the Plan to pre-approve weekly skilled nursing visits and 14 hours a week of a home health aide. You say that you need an aide twice daily. The Plan denied your request. The Plan says your needs can be met with the care currently available to you.
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 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 weekly skilled nursing visits and 14 hours a week of a home health aide. Our reviewer says that these services are not medically necessary at this time. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide medically necessary treatment, care, or services. Your wound care is not complex and your wound is healing without infection. Your medical needs do not require professional 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 weekly skilled nursing visits and 14 hours a week of a home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve weekly skilled nursing visits and 14 hours a week of a home health aide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not currently require 3 hours per day of therapies for 5 days per week. The enrollee's therapy needs can be safely met at a lower intensity setting such as a Skilled Nursing Facility (SNF) 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) provided April 8, 2019.
You asked the Plan to pay for the back brace. You say that the item was medically necessary. The Plan denied
your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a back brace (L0650)
provided April 8, 2019.