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 was admitted to acute care on 1/20/20-1/22/20 with pneumonia, constipation, and dehydration. She has a history of thyroid cancer, hypertension, osteoporosis, and seizure disorder. The enrollee transferred to long term care on 1/22/20. Her prior level of function was living alone and was modified independent with mobility with a cane and activities of daily living. She required assistance with meal prep, laundry, cleaning, and did not drive. Her current level of function is supervision with transfers, supervision with bed mobility, ambulating 100 feet times 2 with a walker and cane with supervision, and standby assist/supervision with grooming, dressing, and toileting. Based on available records, the enrollee does not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily physical therapy and occupational therapy (PT and OT). There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with
mobility and transfers. While she may benefit from continuing PT and OT, the records do not support the need for daily therapy. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on August 22, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say that you do not agree with this decision. You also say that the notes support the need for services. The Plan denied your request. The Plan says the doctor and rendering facility are non-participating providers. The Plan says that there is no in-network referring provider on file. The Plan says that it did not authorize any services for the facility or the doctor. The Plan also says that there are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 an office visit (99214) provided on August 22, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary to avoid overlap of radiation fields. The Plan denied your request. The Plan says this is not supported due to the locations being treated.
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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found despite the basis for the denial being insufficient records and documentation of need, no additional information was provided to support the need for IGRT. i.e. no records specify where in the pelvis the patient is to be treated (either imaging reports that describe metastatic disease in the pelvis or records from the radiation oncologist describing the treatment field). Due to insufficient documentation of need for IGRT, this cannot be considered medically reasonable or 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Questran powder.
You asked the Plan to pre-approve Questran powder. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
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 Questran powder.
Benefits for Questran powder 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the splint and cast application provided on July 5, 2019 and July 12, 2019.
You asked the Plan to waive the copayments for the splint and cast application. You say that these were post-operative visits. You say that you should not have a copayment. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 for each in-network specialist office visit for Medicare-covered services. Covered services include medically-necessary medical care or surgery services furnished in a physician's office. You have been asked to pay $40 for the splint application and a $40 copayment for the cast application. The total amount you owe is $80 ($40 + $40 = $80). The splint and cast application fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for a splint or cast application if performed as a follow-up to a surgical procedure. 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 splint and cast application provided on July 5, 2019 and July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on July 16, 2019 by out of network provider.
You asked the Plan to pay for outpatient lab work. You say that it is the physician's responsibility to obtain prior authorization. The Plan denied your request. The Plan says no authorization was obtained prior to the services in question. The Plan says that the referring provider is also out-of-network.
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 outpatient lab work provided on July 16, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve the requested bed. You say that the enrollee has an injury to her spine. The Plan denied your request. The Plan says there is no indication that coverage criteria has been met.
The Plan follows Medicare rules. Medicare rules say that a semi-electric hospital bed may be considered medically necessary only 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 bed. Our physician reviewer found that the documentation does not support that the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed. The enrollee does not have a medical condition that requires frequent or immediate changes in body position. A physical therapy note indicates the enrollee's improved comfort after being repositioned in bed. Her condition does not require special attachments that cannot be put on an ordinary bed. Therefore, a semi-electric hospital bed 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health physical therapy services.
You asked the Plan to pre-approve continued services. You say that you need additional therapy. The Plan denied your request. The Plan says skilled physical therapy services are no longer medically necessary.
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. Continued services beyond January 16, 2020 were requested. 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 continued services. Our physician reviewer found that you are independent with eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, rolling, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfers, toilet transfers, and car transfers. Your functional level does not require the expertise and skills of a professional therapist. You have been instructed on safe transfers, ambulation, and safety measures. Your functional needs do not require ongoing skills of a professional therapist in home health physical therapy. The documentation does not reveal that home health physical therapy services beyond January 16, 2020 are 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee on February 7, 2019.
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 only one hospital discharge service code is payable per hospital stay.
The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is payable per patient per hospital stay. We looked at the file and Medicare rules. The file shows that more than one hospital discharge code was reported for the date of service at issue. 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 hospital discharge services rendered to the enrollee on February 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on October 16, 2019.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that the medication was ordered through the infusion center instead of the pharmacy. You say that the charge should be $90. The Plan denied your request. The Plan says the coinsurance 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 20% for Medicare-covered Part B medications. You have been asked to pay $231.36, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,156.80 (20% x $1,156.80 = $231.36). The denosumab injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the denosumab injection provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment miscellaneous, battery backup (E1399).
You asked the Plan to pre-approve the battery backup. You say that your electricity goes out frequently and you are unable to sleep. You run out of air and start have very strong tachycardia and this is affecting your health. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. While a backup battery may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment miscellaneous, battery backup (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent office visit (99203) or pay for self-administered drugs (A9270) provided on June 10, 2019.
You asked the Plan to waive the copayment for an urgent office visit and pay for self-administered drugs. You say that because these were urgently needed items and services, they should be fully covered. The Plan denied your request. The Plan says these services processed correctly.
The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for urgently needed services. The enrollee has been asked to pay a $35 copayment for an urgent office visit. An urgent office visit falls within the urgently needed services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. The rules also 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 waive the copayment for an urgent office visit (99203) or pay for self-administered drugs (A9270) provided on June 10, 2019.
Benefits for 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/5/20 following a fall from a horse resulting in multiple rib fractures and bilateral pneumothorax requiring chest tube. He underwent massive transfusion protocol, VATS required, and was transferred to a higher level of care hospital. The complexity of the enrollee's nursing, medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status did not require intensive physician and nursing monitoring that is present in an IRF. The enrollee may benefit from additional physical therapy and occupational therapy but the documentation does not support that the enrollee's functional status and tolerance required an intensive level of therapy that is present 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (71046) provided on September 10, 2019 by out of network provider.
You asked the Plan to pay for the radiology services. You say that you moved and had no idea the services required pre-authorization. The Plan denied your request. The Plan says in-network providers could provide the same services and there was no pre-authorization for out-of-network 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 the radiology services (71046) provided on September 10, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the re-cement or re-bond of a crown provided on July 10, 2019.
You asked the Plan to fully pay for the re-cement or re-bond of a crown. You say that you are to receive the full balance you paid the dentist out of pocket so you get reimbursed. The Plan denied your request. The Plan says this service was performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the service.
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 contract clearly states that you must pay 55% coinsurance for the re-cementation of a bridge, plus anything above the allowable amount, when the services are received out-of-network.
Service
Billed Amount
Allowed Amount
55% Coinsurance
Difference of Billed & Allowed Amount
Member Liability
Prophylaxis
$150
$57
$31.35
$93
$124.35
TOTAL:
$124.35
Therefore, we decided that the Plan does not have to fully pay for the re-cement or re-bond of a crown provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on August 16, 2019 by out of network provider.
You asked the Plan to pay for subsequent nursing facility care. You say that the claim was denied for no authorization. You say that medically necessary services were provided at the request of the medical director. You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications including deterioration, amputation, infection and or hospitalization. You also say that emergency wound care was provided in the absence of another contracted / available wound care physician. The Plan denied your request. The Plan says the Plan and Medicare rules require the member to obtain covered services from Plan providers except for emergency care and out-of-area urgent care. The Plan says that it did not authorize the wound care service provided to the member.
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 subsequent nursing facility care (99308) provided on August 16, 2019 by out of network provider.