Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram and a specialist office visit provided by participating providers on September 15, 2020, to September 29, 2020.

You asked the Plan to waive the copayment for a diagnostic mammogram and a specialist office visit. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment and a $45 copayment for outpatient diagnostic tests/diagnostic procedure and physician/practitioner services/specialist. 

You have been asked to pay a $25 copayment for a diagnostic mammogram and a $45 copayment for a specialist office visit. The total amount you are being asked to pay is $70 ($25 + $45 = $70). A diagnostic mammogram falls within the outpatient diagnostic tests/diagnostic procedure benefit category and a specialist office visit falls within the physician/practitioner services/specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram and a specialist office visit provided by participating providers on September 15, 2020, to September 29, 2020.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF at this time. The March 14, 2021, documentation notes the enrollee is still on Amiodarone drip, has electrolyte abnormalities, and their anemia is being monitored. The March 15, 2021, progress note indicates the plan includes aggressive diuresis. The documentation is not clear that the enrollee's medical issues have been stabilized prior to a transfer to a rehabilitation program. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy can be tolerated an intensive level 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are not medically 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 CardioMEMS. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee a diagnosis of congestive heart failure, as well as heart disease, chronic obstructive
pulmonary disease, and hypertension. The efficacy of the CardioMEMS heart failure system remains uncertain
at this time. Further clinical study is needed to determine the efficacy and safety of this device. Therefore, the
enrollee does not meet criteria for the requested device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not
have to pre-approve CardioMEMS.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.
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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for encephalopathy and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).

You asked the Plan to pre-approve the dental item. You say that The Plan denied your request. The Plan says coverage for an upper denture is limited to 1 every 5 years, per patient, per arch. The Plan says that the frequency limit for the upper denture has been reached.

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 frequency limit of 1 upper denture per arch has been reached. The record shows that the Plan paid for an upper denture that the enrollee received on April 4, 2019. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
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 stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The March 10,
2021, progress note indicates creatinine is worsening and it is not clear if this was stabilizing or improving
prior to a transfer to a rehab program. You may benefit from additional physical and occupational therapy, but
the documentation does not reveal that this therapy can be tolerated or must be only on an intensive level 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on May 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The care provided in this case was not urgent or pre-approved.

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 had network providers available who could have provided 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 nursing facility care (99308) provided on May 12, 2020 by an out of network (OON) provider.
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 stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

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 based on the documentation provided, the health plan's denial of LTACH coverage
should be upheld. The enrollee is currently undergoing treatment at an ACH for CoViD-19. The enrollee is not
intubated/ventilated. 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 LTC 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab (80048, 83540, 36415) and infusion (96365) services provided on October 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the lab and infusion services. You say that these services were medically necessary as a follow-up after the enrollee's surgery. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The services in question were not pre-approved or urgent.

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 had network providers available who could have provided 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 lab (80048, 83540, 36415) and infusion (96365) services provided on October 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve dialysis. You say that this provider is closer to your home. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated at an in-network dialysis facility. The Plan also says that they have approved some dialysis visits with the out-of-network provider in order to transition you to an in-network dialysis facility.

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 dialysis services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel 50mg/ml Sureclick Pen.

You asked the Plan to pre-approve Enbrel. You say that Enbrel is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.

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 Enbrel 50mg/ml Sureclick Pen.

Benefits for Enbrel 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 pre-approve chiropractic treatment to be provided by the out-of-network provider.
You asked the Plan to pre-approve the chiropractic treatment. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. The provider you requested is not part of your primary care physician's 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 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 chiropractic treatment. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic treatment to be provided by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.

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 device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental for use in spinal surgery. More research is needed to show
safety and efficacy of the device. Open laminectomy remains the gold standard procedure for surgically
treating spinal stenosis.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan, 550 mg tablet.

You asked the Plan to pre-approve Xifaxan. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan, 550 mg tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2311, E2377, E2313) and power seat elevation feature (E2300).
You asked the Plan to pre-approve expandable controller. You say that these items are medically necessary for the enrollee. The Plan denied your request. The Plan says the expandable controller is not medically necessary as there is no medical need to control power options through the joystick.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when Medicare criteria cited in the Rules section are met. 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 expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the right upper limb should allow the patient to control any power options with their own switches. In addition, the power seat elevation feature does not primarily serve a medical purpose as specified by the Local Coverage Article Wheelchair Options/Accessories - Policy Article (A52504). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2311, E2377, E2313) and power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital clinic visit provided on July 28, 2020.
You asked the Plan to pay for the hospital clinic visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 hospital clinic visit. 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 hospital clinic visit provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466)
You asked the Plan to pre-approve non-invasive home ventilator. You say that this item is medically necessary.
The Plan denied your request. The Plan says this is not medically necessary for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 non-invasive home ventilator. Our
reviewer says that the requested ventilator is not medically necessary and reasonable. Our physician reviewer
found the enrollee may qualify for Bilevel Positive Airway Pressure (BiPAP) support at home, with
documentation of CO2 retention on arterial blood gas testing while stable. However, Medicare does not cover
a home ventilator when used as BiPAP.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-invasive home ventilator have not been met. Therefore, we decided that the
Plan does not have to pre-approve a non-invasive home ventilator (E0466)