Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to a colorectal surgeon for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says a highly specialized technical level of care is not medically necessary.
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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not support in this case the medical necessity for evaluation with a highly specialized (tertiary care) physician. Rather, the enrollee's co-morbidities, general condition, and past medical history as evidenced by available records are within the purview of specialty care that is readily available to the enrollee in his in-network locale. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level referral to a colorectal surgeon for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio (J3380) infusions, 300mg every 4 weeks.You asked the Plan to pre-approve the increased dose frequency for Entyvio. You say that the enrollee is no longer responded to the standard dosing so an increased dose frequency is required.The Plan denied your request. The Plan says that the increased dose is not medically necessary.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 the increased dose frequency for Entyvio. Our reviewer says that the requested infusions are medically necessary. Our physician reviewer found that studies have shown that increased dosing frequency might improve outcomes in patients who lose response to conventional 8-weekly dosing. The above conclusion is supported by the AGA 2016 Clinical Care Pathway and follow up studies. The record shows the enrollee's clinical information supports an increased dosage.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 increased dose frequency for Entyvio have been met.Therefore, we decided that the Plan has to pre-approve Entyvio (J3380) infusions, 300mg every 4 weeks.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetranscutaneous electrical nerve stimulation (TENS) device (E0730).You asked the Plan to pre-approvethe TENS device. You say that you need this device to recover movement on your face muscles.The Plandenied your request. The Plan says the records do not support that the enrollee meets the criteria.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 TENS device. Our reviewer says that the requested items/services are not considered medicallyreasonable and necessary in this case. Our physician reviewer found the enrollee has pain and muscle dysfunction of one side of the face due to Bell's Palsy and has requested a TENS unit for treatment of this. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. The requested TENS unit is not medically reasonable and 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 the TENS device have not been met.Therefore, we decided that the Plan does not have to pre-approvetranscutaneous electrical nerve stimulation (TENS) device (E0730).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for venipuncture services provided on January 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for venipuncture services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for venipuncture services provided on January 29, 2020 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 would be better suited to manage this enrollee's care. The Plan denied your request. The Plan says there is no service that an LTACH can perform that cannot be performed in the current setting. Therefore, transfer to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 an 87-year-old male with a past medical history of end stage renal disease on dialysis, diabetes, coronary artery disease and peripheral artery disease who presented to the acute hospital on 07/16/2020 with a right foot ulcer with infection and gangrene. He was treated in the hospital with intravenous antibiotics and underwent a right femoral artery to peroneal artery bypass procedure. He has dry dressings to the right lower extremity. He reportedly has had confusion and has had some refusal to work with physical and occupational therapy due to pain. Overall he reportedly is not making progress with therapy. He is weight bearing as tolerated and is walking only a few feet with a rolling walker and is moderate to maximum assist for transfers and activities of daily living. He is medically stable. Transfer to a long-term acute care hospital is requested. The short-term acute care hospital can provide for all the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on February 3, 2020 and February 17, 2020.You asked the Plan to waive the copayments for outpatient mental health care. You say that you disagree with the charges.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 $50 copayment for out-of-network outpatient mental health care. You received outpatient mental health care on February 3, 2020 with an out-of-network provider. Therefore, you are responsible to pay the $50copayment. You received outpatient mental health care on February 17, 2020 with an out-of-network provider. Therefore, you are responsible to pay the $50 copayment.The total amount you owe is: $100.You have been asked to pay the total copayment amount of $100for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 copayments for outpatient mental health care provided on February 3, 2020 and February 17, 2020.
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
February 20, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment because the plan advised you to go to an out-of-network provider. 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 services obtained from a specialist, or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.
You have been asked to pay a $50 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
you were billed for a specialist office visit by an in-network provider. The record also shows that you were not
charged for the hearing test.
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 February 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you can receive skilled therapy and/or skilled nursing services on an
intermittent basis under Part B benefits.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on March 10, 2020 by an OON provider.You asked the Plan to pay for the endodontic therapy. You say that you were referred by your regular dentist to see this provider. You also say that the service was medically necessary.The Plan denied your request. The Plan says this service was performed by a dentist who does not participate with the dental plan. The Plan also says services are not covered when rendered by a dentist who does not participate with the dental plan.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the endodontic therapy provided on March 10, 2020 by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), and the
office visits (99213, 99203) rendered by the out of network (OON) provider from February 17, 2020 to April 7,
2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The office visit of February 17, 2020 is a non-covered service as the Plan only covers manual manipulation of
the spine to correct a subluxation. Additionally, the record shows that per your call to the Plan on February 20,
2020, you were advised that a contracted provider must be utilized for chiropractic services; a list of providers
was subsequently mailed to you. The 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 services at issue.
We found no exception that would require the Plan to pay for these services. In addition, the record shows that
manual manipulation of the spine was billed without an AT modifier. This is a billing issue according to
Medicare rules. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative
treatment (98941), and the office visits (99213, 99203) rendered by the out of network (OON) provider from
February 17, 2020 to April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on March 13, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.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. We looked at the file and Medicare rules. There are no records to support that you have a subluxation of the spine as required by 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 pay for the chiropractic services rendered on March 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home blood testing.You asked the Plan to pre-approve home blood testing. 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 medically necessary.The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be 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 home blood testing. Our reviewer says that the documentation does not support that you are currently homebound. Our physician reviewer found while the physician appeal letter states that you are homebound, the recent medical progress reports do not indicate that leaving the home is a considerable and taxing effort for you. The documentation does not indicate that you need specialized transportation (i.e. for a wheelchair). The documentation does not indicate use of a supportive device to leave the home. The documentation does not reveal that you need assistance of another person to leave the home except to drive you somewhere. Therefore, you do not meet criteria for the requested home 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 home blood testing have not been met.Therefore, we decided that the Plan does not have to pre-approvehome blood testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by an in-network hospital on March 6, 2020.You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this should be covered fully. The Plan denied your request. The Plan says the correct copayment has been applied.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 clearlysays that you must pay a $225 copayment for outpatient surgery/hospital facility. You have been asked to pay a $225 copayment for a diagnostic colonoscopy. Evidence was provided to verify a poly was removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. Adiagnostic colonoscopy falls within theoutpatient surgery/hospital facility 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 a diagnostic colonoscopy provided by an in-network hospital on March 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve8 physical therapy (PT) visits (G0151) and 10 home health aide visits (G0156).You asked the Plan to pre-approve8 PT visits and 10 home health aide visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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-approve8 PT visits and 10 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided the documentation does not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The documentation does not show that home health aide services are reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 PT visits and 10 home health aide visits have not been met.Therefore, we decided that the Plan does not have to pre-approve8 physical therapy (PT) visits (G0151) and 10 home health aide visits (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program.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.