Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after January 23, 2020.
You asked the Plan to pre-approve SNF care. You say that the enrollee is bed-ridden which causes wounds and is not able to go home alone. The Plan denied your request. The Plan says the denial of authorization for additional SNF care is correct, because the enrollee has exhausted the 100-day SNF benefit covered by Medicare and the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from October 6, 2019 to January 23, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 3, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not diagnosed correctly. You say that the visit should be covered in full or denied to the provider. 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 $65 copayment for Medicare-covered urgently needed care services. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you received services during the urgent care 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 urgent care visit provided on July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 5, 2019 by the out of network provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the routine physical provided on September 18, 2019.
You asked the Plan to waive the coinsurance for the routine physical. You say that you were unaware that the provider was out-of-network. You say you were told there was no copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 35% coinsurance for an out-of-network annual routine physical. You have been asked to pay a total of $84.06 which is 35% of the allowed amount for the routine physical. The allowed amount is $240.20. ($240.20 x 35% = $84.06). The routine physical falls within the "Annual routine physical" 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 routine physical provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the K3 prosthetic knee coded as L5822 and L5845.
You asked the Plan to pre-approve K3 prosthetic knee L5822 and L5845. You say that the enrollee has been using an advance feature knee and now needs a lighter weight stable knee. The Plan denied your request. The Plan says request for K3 prosthetic knee does not meet Medicare criteria as reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve K3 prosthetic knee L5822 and L5845. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show the need for the advanced knee feature. More documentation is needed to show that the patient needs the advanced knee feature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of K3 prosthetic knee L5822 and L5845 have not been met. Therefore, we decided that the Plan does not have to pre-approve the K3 prosthetic knee coded as L5822 and L5845.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy (97140) and an occupational therapy evaluation (97165) provided on August 19, 2019 by an out of network provider.
You asked the Plan to pay for manual therapy and an occupational therapy evaluation. You say that these are Medicare-covered services. The Plan denied your request. The Plan says these services 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 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 manual therapy (97140) and an occupational therapy evaluation (97165) provided on August 19, 2019 by an out of network provider.
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 enrollee really wants to use the requested IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional therapy of physical therapy and occupational therapy, but the enrollee does not require this on an intensive rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the provider office will not allow you to pay out-of-pocket. The Plan denied your request. The Plan says you have in-network specialists available in your service area.
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 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. 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 the medical services to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services out-of-area.
You asked the Plan to pre-approve the out-of-area physical therapy services. You say that the enrollee fell and was in the hospital until November 3, 2019. You say that the enrollee was moved back to a skilled nursing facility (SNF) until November 9, 2019. You say that the enrollee was picked up by her family and brought back to Texas for support and care while recovering. You say that once the enrollee is well, she will go back to Oregon. You say that at this time the enrollee needs to be with family to care for her and make sure she gets to and from her appointments for recovery. The Plan denied your request. The Plan says this is not an emergency situation. The plan says that the enrollee must receive care from a network provider.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The case file shows that the need for the services being requested were not unforeseen prior to leaving the service area. Based on this information, we decided that Medicare rules for coverage of the out-of-area care have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services out-of-area.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection of betamethasone acetate and betamethasone sodium phosphate (J0702) provided by the physician on October 17, 2019.
You asked the Plan to waive the copayment for an injection. You say that you do not feel liable for the services. The Plan denied your request. The Plan says Medicare Part B prescription drugs have a 20% coinsurance
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for an injection. This service falls within the Medicare Part B prescription drugs benefit category (The allowed amount $28.22 x 20% = $5.64). 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 injection of betamethasone acetate and betamethasone sodium phosphate (J0702) provided by the physician on October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 23, 2019.
You asked the Plan to pay for this claim. 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 requested 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 medical services provided to the enrollee on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Mobile Stairlift.
You asked the Plan to pre-approve a battery powered and portable stair wheelchair (K0899). You say that the enrollee does not have a ramp and cannot get out of the house for appointments. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that this type of wheelchair has not been approved by Medicare. While a portable stair lift wheelchair 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 a Mobile Stairlift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that you are unable to move from your home. The Plan denied your request. The Plan says there is no order for a power wheelchair.
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under certain medical indications. We looked at the file and Medicare rules. The medical records provided do not include a written order from your provider for a power wheelchair. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for (A4623), (A4624), (A4629), (A6402), (A7000), (A7002), (A7525) and (A7526) provided to the enrollee on July 15, 2019.
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 that the services are not supported.
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 DME have been met. The provider sent us information to verify that the services are supported. Therefore, we decided that the Plan has to pay for (A4623), (A4624), (A4629), (A6402), (A7000), (A7002), (A7525) and (A7526) provided to the enrollee on July 15, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on February 21, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Based on the documentation provided it does not appear that criteria for coverage were met. There was objective evidence that the GY modifier was reasonable. The member did not have an emergent condition at the time of transfer and was not bed bound. The member had an adult son present who was able to secure transportation himself to the emergency room to meet the ambulance there. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on February 21, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Fx (J7321).
You asked the Plan to pre-approve Supartz Fx. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 Supartz Fx. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Orthovisc has been tried and failed. The documentation does not support that Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The enrollee has not tried and failed both Orthovisc and Monovisc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz Fx have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Fx (J7321).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 29, 2018 through August 31, 2018.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the services are not authorized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 29, 2018 through August 31, 2018.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.