Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is not intubated or ventilated. There is no evidence that the enrollee
requires services that are not currently available. The facility the enrollee is currently at can provide the same
level of care as an LTACH. There is no benefit to transferring the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
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 SNF care. You say that the enrollee needs SNF care and is still not ready to
come home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF care 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca 6 mg/0.6 ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no indication of a trial with Neulasta, Fulphila, and Nyvepria.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, the enrollee has not tried and failed the required drugs. There is no indication that the
required drugs would likely be less effective and/or likely have adverse effects.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Udenyca 6 mg/0.6 ml for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee is currently in the hospital under observation for weakness. The enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's functional level is near baseline and 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 in a SNF. Skilled nursing or therapy services are not required on a daily basis or, as a practical matter, 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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 9, 2020.
You asked the Plan to pay for the x-rays. You say that it was your provider's responsibility to inform you that
these additional x-rays would not be covered. You cannot afford this bill. The Plan denied your request. The
Plan says they already paid for a set of bitewing x-rays for you on November 16, 2020. Bitewing x-rays are
only covered for one set per calendar year. This information is outlined in your contract.
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 were
provided in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan
does not have to pay for the bitewing x-rays (D0274) provided on December 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met in the current inpatient rehab facility, if approved by the health
plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by code E2100.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order for the billed product for the billed date of service; therefore, the billed service cannot be verified.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order to support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) defined by code E2100.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can received the needed care in a different setting.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fentanyl patch for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is 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 pre-approve the Fentanyl patch for the enrollee.
Benefits for this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a home ventilator.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no urgent or emergent medical condition.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient mental health visit provided on September 10, 2020.

You asked the Plan to waive the copayment for an outpatient mental health visit. You say that you were not satisfied with this service. The Plan denied your request. The Plan says this processed 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 $35 copayment for outpatient mental health care. 

You have been asked to pay a $35 copayment for an outpatient mental health 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 an outpatient mental health visit provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 7, 2020.

You asked the Plan to pay for the dental service. You say that the benefit summary is leading confusion as the Plan was misleading suggesting that one can receive 2 cleanings but only if one is strictly attentive to the month's intervention the cleaning. You say that The Plan denied your request. The Plan says prophylaxis is covered once every 6 months, up to 2 visits every calendar year. The Plan also says that the number of visits within the allotted time frame has been exceeded.

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 and prophylaxis is listed as a covered service, coverage is limited to once every 6 months, up to 2 visits every calendar year. The record shows that the Plan paid for the prophylaxis that you received on July 15, 2020 less than 6 months prior. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided January 1, 2021.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied
your request. The Plan says the billed code has a column I / column II relationship with another code billed and
is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045
has a Column I / Column II relationship with code 36556 and cannot be paid as billed. This code cannot be
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided January 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the CT scans and the contrast material provided on October 3, 2020.
You asked the Plan to waive the cost share for the CT scans and the contrast material. You say that you have had the same CT scans done in the past and have only been charged for one scan. The Plan denied your request. The Plan says you have been asked to pay 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic) and 20% coinsurance for each Medicare-covered medical supply. You have been asked to pay a total of $284.97 for the CT scans and the contrast material. The CT scans and the contrast material fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment/
Coinsurance
Member Liability
October 3, 2020
CT scan, abdomen and pelvis
$315.67
$160
$160
October 3, 2020
CT scan, thorax
$122.99
$160
$122.99
October 3, 2020
Contrast material
$9.90
20%
$1.98
Total
$284.97
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 cost share for the CT scans and the contrast material provided on October 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve ventriculography.
You asked the Plan to pre-approve ventriculography. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the records do not describe worsening symptoms or a 12-week trial of treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 ventriculography. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has increasing exertional dyspnea symptoms possibly consistent with angina and ischemic heart disease along with a pretest probability for coronary artery disease. She is on a good regimen of antihypertensives, statins, and beta blockers but has persistent symptoms despite this. She had a recent nuclear stress test which was notable for both apical infarction and ischemia. Given her increasing and persistent symptoms despite a reasonable guideline-directed medical regimen, and evidence of ischemia on non-invasive testing, she would meet the clinical indications for left heart catheterization, coronary angiography, and left ventriculography 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 ventriculography have been met. Therefore, we decided that the Plan has to pre-approve ventriculography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced knee and foot for a lower limb prosthesis.
You asked the Plan to pre-approve advanced features. The Plan denied your request. The Plan says the records do not show why the advanced foot and knee are needed.
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses 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 advanced features. Our physician reviewer found that there is no documentation that the enrollee has the ability to traverse most environmental barriers, or may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. An annual wellness visit indicates that you are non-ambulatory and use a wheelchair for mobility. Therefore, the requested features are not 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 advanced features have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced knee and foot for a lower limb prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is not safe to go to a lower level of care. The Plan denied your request. The Plan says the enrollee's care is not complex, and she does not need a team of providers.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that the enrollee was admitted to the acute care hospital for acute on chronic respiratory failure and interstitial pneumonia. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.