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

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on October 29, 2019 and December 6, 2019.You asked the Plan to waive the copayments for the specialist office visits. You say that you have been seeing this doctor monthly and have never been asked to pay a copayment. 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 $15 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $15 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 the specialist office visits provided on October 29, 2019 and December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on July 21, 2019 through July 24, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because the inpatient admission was medically necessary.The Plan denied your request. The Plan says that the clinical documentation does not support the inpatient 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 supports that the criteria for inpatient payment are met inthis case. Our physician reviewer found the record showed 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 forthe acute inpatient hospital care provided on July 21, 2019 through July 24, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the chest.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have recently-reported shortness of breath with exertion and had a stress test and echocardiogram performed. The stress test showed no reduced blood flow (ischemia). The records do not support that a CTA is reasonable and medically necessary to further evaluate your symptoms.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon October 21, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 physician's services provided on October 21, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe total electric hospital bed.You asked the Plan to pre-approvethe total electric hospital bed. You say that you are requesting coverage because you cannot sleep in your regular bedThe Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvethe total electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on September 17, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were provided in good faith.The Plan denied your request. The Plan says no prior authorization was obtained.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 requestedprovider 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 forskilled nursing services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health services provided on October 18, 2019 through October 30, 2019.You asked the Plan to pay forthe inpatient mental health services. You say that you would like reconsideration because these services were medically necessary.The Plandenied your request. The Plan says prior authorization was not obtained by the provider or facility.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 the inpatient mental health services. Our reviewer says that it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the member did not have dangerousness to self or others but was compliant with treatment.Our physician reviewer found it did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the member's condition or for the purpose of diagnosis beyond the date in question. 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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health services provided on October 18, 2019 through October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean established patient office visit with an out-of-network provider.You asked the Plan to pre-approvethe out-of-network established patient office visit. You say that this was paid in the past and that you are in desperate need of this blood test now. You say that you need continuity of care.The Plan denied your request. The Plan says the enrollee does not have needs that can only be addressed by the requested out-of-network provider.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 out-of-network established patient office visit. Our reviewer says that the criteria for coverage of out-of-network care have not been met. Our physician reviewer found the enrollee has diagnoses of thrombocythemia and monoclonal gammopathy. She is treated with oral Hydrea. Per the documentation, the enrollee's last office visit with hematology was October 17, 2019. The treatment plan was to continue her long standing Hydrea treatment and repeat labs in one month.  She would then follow-up with the provider in appropriately 4 months. The enrollee has a chronic hematologic condition which is being actively treated with oral medication. It is medically necessary that this treatment be continued under the care of a qualified hematologist. However, the enrollee is not currently receiving any active treatment and/or medical management of her condition that makes it medically necessary for this enrollee to continue care specifically with the out-of-network doctor as requested. There is not anything unique about this enrollee's condition that would make it medically necessary for her to continue care specifically with the out-of-network provider. The plan has shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. This enrollee's medical management and follow-up care can be safely transitioned to an in-network specialist at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network care has not been met. Therefore, we decided that the Plan does not have to pre-approvean established patient office visit with an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI.The Plan denied your request. The Plan says the requested MRI is not medically reasonable and necessary. The Plan says that the medical records provided do not show that the enrollee has sinusitis, polyposis, or a suspected tumor in the nasal cavity.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the requested MRI is not medically necessary at this time. Our physician reviewer found the enrollee's symptoms and medical condition does not warrant a MRI scan at this time. MRI is rarely indicated for chronic sinusitis. A MRI scan can be indicated for an invasive process such as a malignancy or infectious process. The enrollee was seen by ear nose and throat (ENT) provider in 2019 and an MRI was not ordered at that time. In addition, the enrollee recently had an MRI brain done. Although an MRI of the brain does not cover the neck, the enrollee does not have an aerodigestive tract abnormality that warrants an MRI scan.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator to treat obstructive sleep apnea.You asked the Plan to pre-approve the requested services. You say that a CPAP has failed to work.The Plan denied your request. The Plan says the service is not reasonable and 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 requested services. Our physician reviewer found that the clinical information indicates you have been using a CPAP for many years with good tolerance and benefit. The sleep study shows normalization of disordered breathing with CPAP, indicating it is effective. It appears you are requesting this treatment primarily for travel convenience. Therefore, the requested service is considered not 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 the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator to treat obstructive sleep apnea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor for the enrollee.You asked the Plan to pre-approvethe requested device. You say that the enrollee needs better management and tracking of glucose levels.The Plan denied your request. The Plan says the enrollee is not on insulin.The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under certain medical indications. 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 requested device. Our physician reviewer found that the enrollee is only on oral medications. The coverage criteria require insulin use with frequent adjustments in insulin dosing according to blood glucose levels. There is no reason given why glucometer checks alone are not sufficient for this enrollee. Therefore, the requested device is not 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from October 31, 2019 to November 3, 2019.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be charged this amount. You say there is no way you can pay a $525 bill. 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 $175 copayment per day per admission for days 1-3 for in-network inpatient hospital care. You have been asked to pay a $175 copayment for each day of the inpatient hospital stay. ($175x 3 = $525). The inpatient hospital stay falls within the "Inpatient hospital 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 inpatient hospital stay provided from October 31, 2019 to November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor and reader.You asked the Plan to pre-approve continuous glucose monitor. You say that it is imperative that you monitor glucose each morning, however you cannot use other testing methods.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because you are on oral medication and not on an intense regimen of insulin.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 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 continuous glucose monitor. Our reviewer says that you do not meet the Medicare criteria for the requested continuous glucose monitor. Our physician reviewer found you are on medications that will not cause hypoglycemia and there is no mention of your overall control to suggest the importance of blood glucose monitoring, there is not enough data at this time to justify use of a continuous glucose monitoring given Medicare criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor sensor and reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveDarzalex, Pomalyst and Dexamethasone for the enrollee.You asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysthe use of this drug requires that at least two prior therapies, including an immunomodulary agent and proteasome inhibitor, are received.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the requested drugs arenot FDA-approved for this enrollee's diagnosis. There are no major drug compendia or clinical research that supports these drugs for the enrollee.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 drugs have not been met.Therefore, we decided that the Plandoes not haveto pre-approveDarzalex, Pomalyst and Dexamethasone for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laminectomy, facetectomy and foraminotomy (63047).
You asked the Plan to pre-approve the laminectomy, facetectomy and foraminotomy. You say that you would like reconsideration because this service is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this would not be the standard of care for the member at this time.
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 laminectomy, facetectomy and foraminotomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show evidence or severe spinal stenosis on imaging films. 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 laminectomy, facetectomy and foraminotomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a laminectomy, facetectomy and foraminotomy (63047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair and accessories to increase independence in the home and navigate from doorway to Handivan for medical appointments.The Plan denied your request. The Plan says the price quote has expired.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the quote for a Group 3 power wheelchair and accessories was written May 24, 2019 and has expired. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.