Persius/hicric huggingface dataset:
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a perforated bowel. The enrollee was hospitalized less than a month ago and underwent a series of surgeries to repair her bowel. She was intubated/ventilated prior to the initial surgery and received a tracheotomy on July 25, 2020. The enrollee is tolerating ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 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 ACH until such time no acute services are required. The enrollee can 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy provided from November 21, 2019 to November 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient therapy. You say that the services meet medical necessity standards. You say that the claim should be reprocessed for benefits due. The Plan denied your request. The Plan says the services received were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. 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 outpatient therapy provided from November 21, 2019 to November 30, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee on December 10, 2019.You asked the Plan to pay these services. You say that this claim should be paid.The Plan denied your request. The Plan says insufficient records were provided to support the claim billed.The Plan must follow Medicarerules. Medicare has specific coverage criteria for this type of drug testing.  Medicare rules say that physicians and providers must produce medical records showing why the testing servicesprovided were medically necessary. In this case, there were insufficient records provided to show the results of this testing would be used to determine a diagnosis or determine a treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes and when multiple tests are done at one time. The physician order provided does not meet these criteria.Based on this information, we decided that Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November
20, 2019 to December 3, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the patient's condition did not meet the definition of medical
necessity for an 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 does not support that the criteria for inpatient payment are met in this case. The
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the
patient's necessary hospital care (including earlier emergency department and/or observation care) would span
two midnights. The patient was admitted for cognitive decline/placement. Her condition did not meet the
definition of medical necessity for an inpatient level of care. The records sent did not show that the patient had
ataxia, diplopia, visual field loss, nystagmus or paralysis. Furthermore, the records did not show that there was
concern for or findings of epilepsy, stroke or transient ischemic attack. Our physician reviewer found that the
enrollee's condition does not meet Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from November 20, 2019 to December
3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the laboratory services provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 17, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 4, 2020.You asked the Plan to pay for this claim. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider 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 physician services provided to the enrollee on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for a specialist telehealth visit provided on March 16, 2020.You asked the Plan to waive this copayment. You say that the office staff did not tell you there would be a copayment.The Plan denied your request. The Plan says this copayment was charged per the Plan contract agreement.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 $45 copayment for telehealth specialist visit. 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 $45 copayment charged for a specialist telehealth visit provided on March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveReblozyl.You asked the Plan to pre-approveReblozyl. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Reblozyl. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have high-risk Myelodysplastic syndromes based on a IPSS-R score of 6. The requested drug, luspatercept (Reblozyl), is indicated for low to moderate risk MDS. The documentation does not support that the enrollee meets criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met.Therefore, we decided that the Plan does not have to pre-approveReblozyl.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided from 10:27 AM
on October 9, 2019 through October 14, 2019.
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that the post stabilization care was not authorized.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post stabilization inpatient care. Our
reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. The
documentation does not show that the treating physician documented (in the physician notes, on a form, or in
an order) that the patient was not stable for transfer on any dates of service. Our physician reviewer found that
the patient was stable to transfer by ambulance to an in-network hospital as of 10/09/2019 at 10:27 AM.
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 post stabilization inpatient care have not been met. Therefore, we decided
that the Plan does not have to pay for the post stabilization inpatient care provided from 10:27 AM on October
9, 2019 through October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for telehealth services provided
on March 19, 2020.
You asked the Plan to waive this copayment. You say that the office staff told you there was no copayment and
then told you there was a copayment. You say that had you known there was a copayment you would not have
had a telehealth visit. The Plan denied your request. The Plan says this copayment was charged based on the
Plan contract agreement and the claim submitted by your provider.
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 $45
copayment for specialist visits and that includes telehealth. 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 $45 copayment charged for
telehealth services provided on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on March 10,
2020.
You asked the Plan to pay for the endodontic therapy. You say that you called the Plan prior to receiving the
service and were told that the root canal would be covered at 40% instead of 50% because the provider was
out-of-network. The Plan denied your request. The Plan says this service is not a covered benefit under your
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
among those covered under this benefit. The records show that the Plan reviewed their call history and verified
that you were not given any misinformation. The Plan representative advised you that the root canal was not
covered, that the treating provider was out-of-network, and you had a $1,000 dental limit. Therefore, we
decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Beovu (Brolucizumab-DBLL).
You asked the Plan to pre-approve Beovu. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Beovu. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Exudative age-related macular degeneration, right eye, with active choroidal neovascularization. The documentation does not support a trial and failure of Bevacizumab. The documentation does not support that Bevacizumab would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Beovu have not been met. Therefore, we decided that the Plan does not have to pre-approve Beovu (Brolucizumab-DBLL).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 24, 2020. You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider 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 physician services provided to the enrollee on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TTE.
You asked the Plan to pre-approve the TTE. You say that you would like reconsideration because the TTE is
medically necessary. The Plan denied your request. The Plan says the clinical information provided does not
describe a Medicare covered indication for this service.
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 TTE. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record includes no documented cardiac symptoms, no documented cardiac physical exam
abnormalities and no electrocardiographic abnormalities.
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 TTE have not been met. Therefore, we decided that the Plan does not have
to pre-approve TTE.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and suspension sleeves
(L2397) provided to the enrollee on November 22, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is
medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
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 orthoses and sleeves have not been met. No medical records
were received to support the diagnosis on the submitted order; therefore, the bill code cannot be supported.
Multiple attempts to obtain addition information have been made; therefore the billed supply code cannot be
verified. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and
suspension sleeves (L2397) provided to the enrollee on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vibramycincapsules, Norvasc tablets, Lipitor tablet, Prozac pulvules, Lasix tablets, and Zestril tablet provided on February 10, 2020 and February 11, 2020You asked the Plan to pay for the self-administered drugs. You say that you are unsure of what these charges are for.The Plan denied your request. The Plan says the drug is a self-administered drug, and not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the Vibramycin capsules, Norvasc tablets, Lipitor tablet, Prozac pulvules, Lasix tablets, and Zestril tablet provided on February 10, 2020 and February 11, 2020Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician 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 physician services provided on November 12, 2019 by an out of network (OON) provider.