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).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested
admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested
admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility
(SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the
enrollee admitted to acute care on 2/28/20 diagnosed with subluxation of right foot. On 2/28/20 she underwent
an open reduction internal fixation (ORIF) of the right midfoot first and second joints and closed treatment for
right fourth metatarsal base fracture. On 2/27/20 she was discharged back to hospital for surgical repair of right
foot. She had no significant post-operative complications. She is non-weight bearing for bilateral lower
extremities. Short and long term goals in therapy not achieved due to discharge to hospital for surgery. On
2/27/20 she needed moderate assistance for rolling, moderate assistance for supine to sit, bed to wheelchair
dependent with mechanical lift, and was able to propel a wheelchair with bilateral upper extremities with
maximum assistance.
This enrollee 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
enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled
nursing need. This enrollee's functional status does not require skilled therapy services with the specialized
skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically
necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy
services (or a combination of these services) on a daily basis. As a practical matter this enrollee 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we
decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 is a perfect candidate for LTACH care. The Plan denied your request. The Plan says the enrollee's needs can be met in the current acute care hospital.

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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the head and brain (70470).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is 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 CT scans 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 CT scan. Our reviewer says that a CT scan is not medically necessary. Our physician reviewer found there is no evidence the member has dementia or other cognitive loss or findings that would support medical necessity for the head CT scan. The enrollee's neurological exam is normal. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the head and brain (70470).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on September 6, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that this was your annual eye exam. You say that you do not have a copayment. The Plan denied your request. The Plan says the copayment 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 $35 for each specialist visit for a Medicare-covered eye exam. You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that this was a medical eye exam. 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 eye exam provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 11, 2019 under codes 80307 and G0483.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan says that codes 80307 and G0483 remain not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed. It is noted multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on June 11, 2019 under codes 80307 and G0483.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that this should be covered. The Plan denied your request.
The Plan says no records were submitted to demonstrate medical necessity.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. No medical records were submitted. Medical necessity cannot be
established. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been
met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (CPT Code E0260) provided on November 2, 2019.
You asked the Plan to pay for the hospital bed. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 the hospital bed have not been met. The criteria for coverage of semi-electric bed includes a requirement for frequent changes in body position and/or has immediate need for a change in body position. As the documentation by ordering provider states the need for positioning at a 45 degree fixed angle, this can be achieved by alternative means and does not meet this criteria. Therefore, we decided that the Plan does not have to pay for hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (CPT Code E0260) provided on November 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - resin-based composite (indirect) (D2710 X 4) provided on August 19, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You asked for six (6) extractions (D7210 x 6). Your EOC provides a benefit for 2 extractions every calendar year with a 0% co-insurance. The Plan has paid for 2 of these extractions per your EOC. You do not meet the conditions for approval of four (4) additional extractions because you exceeded the number of allowed extractions for the year. Your request for an additional 4 extractions is still unable to be approved. Therefore, we decided that the Plan does not have to pay for crown - resin-based composite (indirect) (D2710 X 4) provided on August 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.
You asked the Plan to pre-approve routine transportation. You say that you have no way of getting to the wound center for treatment. The Plan denied your request. The Plan says that this is not covered by the Plan.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350) provided on
October 29, 2019.
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you were not aware that
these services were not covered. The Plan denied your request. The Plan says this service is not a covered
benefit.
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 2D
oral/facial photographic images (D0350) provided on October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee.
You asked the Plan to pre-approve the drug. You say that this will very likely treat both the enrollee's asthma and his sinus/nasal polyps and will hopefully prevent the need for surgery. The Plan denied your request. The Plan says that this is not covered under the member's plan under any normal circumstances.
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 Dupixent for the enrollee.
Benefits for the 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the member's needs can be met at a lower level of care such as long-term care.
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 the enrollee's condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
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 unable to care for yourself after knee surgery. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital and had incision and drainage to your knee on February 25, 2020. You need assistance with transfers and walking 130 feet. The complexity of your medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full size bed with pillow top mattress.
You asked the Plan to pre-approve the full size bed with pillow top mattress. You say that you do not have the funds to purchase a full size bed with pillow top mattress yourself. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 full size bed with pillow top mattress have not been met. You are able to transfer on and off your current hospital bed. You benefit from the hospital bed to maintain safety with bed mobility. You are able to lay on your side with the cat in bed and a full size bed would take up more space in your room, leading to increased clutter and increasing the risk of falls as well as mental health exacerbation. Occupational therapy is able to discuss other options for making your current bed more comfortable. Therefore, we decided that the Plan does not have to pre-approve a full size bed with pillow top mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physicians services. You say that you perform these services in good faith and should be fully reimbursed. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystourethroscopy provided on April 5, 2018.
You asked the Plan to reduce the copayment for the cystourethroscopy. You say that you were an ambulatory patient and should not be charged as an outpatient. 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 $200 copayment for medical or surgical procedures/treatments received in an outpatient hospital facility, or clinic, including your doctor's office. You have been asked to pay a $200 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you had this surgery at an outpatient 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 reduce the copayment for the cystourethroscopy provided on April 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 17, 2018.
You asked the Plan to waive the copayment for the office visit. You say that you previously received an endoscopy and did not go back for any other treatments. You say that you thought this bill was resolved. The Plan denied your request. The Plan says the copayment 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 $25 copayment for a specialty physician. You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were seen for a follow up 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 office visit provided on December 17, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport . You say that you had no choice but to go by ambulance. You say that you need help with the bill. The Plan denied your request. The Plan says the copayment 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 $265 copayment per date of service regardless of the number of trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 ambulance transport provided on October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve self-administered Prednisone for the enrollee.
You asked the Plan to pre-approve this request. You say that this drug is medically necessary. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare 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 self-administered Prednisone for the enrollee.
Benefits for this request may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.