Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PT performed by a qualified physical therapist in the home health setting (G0151), services of an HHA (G0156), and skilled services by a RN (G0162).

You asked the Plan to pre-approve the PT, services of an HHA, and skilled services by a RN. You say that you would like to receive PT services at home because you cannot walk and get out of bed. You also say that you are unable to leave your home for therapy services. The Plan denied your request. The Plan says the documentation does not show the medical necessity to have this level of care.

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.

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 PT, services of a HHA, and skilled services by a RN. Our reviewer says that these services are not medically reasonable and necessary. Our physician reviewer found the documentation does not support that you require in-home skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The documentation does not support that you are homebound. Our reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that the requested home health services are not medically necessary as the member can receive services on an outpatient basis.

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 PT, services of a HHA, and skilled services by a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve the PT performed by a qualified physical therapist in the home health setting (G0151), services of an HHA (G0156), and skilled services by a RN (G0162).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iStent placement for the enrollee.
You asked the Plan to pre-approve the placement. You say that this is medically necessary. The Plan denied your request. The Plan says there is no diagnosis of glaucoma.
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 placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee underwent treatment for cataract and had the requested device placed due to elevated intraocular pressures from open angle glaucoma. The provided medical records do not indicate that the enrollee had prior failure of filtering/cilioablative procedure and/or uncontrolled IOP (progressive damage and mean diurnal medicated IOP 20 mm or more Hg) on maximally tolerated medical
therapy (i.e., 4 or more classes of topical IOP-lowering medications, or fewer in the case of tolerability or efficacy issues). 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 placement have not been met. Therefore, we decided that the Plan does not have to pre-approve iStent placement for the enrollee.
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. The Plan denied your request. The Plan says IRF admission 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 that 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
enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown and core buildup provided on August 4, 2020.

You asked the Plan to pay more for the crown and core buildup. You say that you were informed you could go out-of-network with no penalties. You say that you expected the crown to be fully covered and you did not get reimbursed the amount you paid. The Plan denied your request. The Plan says the claim processed correctly.

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 Plan is only obligated to pay the maximum allowable charge. You are responsible for any amount greater than the payment made by the Plan to the out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the crown and core buildup provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) (CPT code 43775), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. The Plan denied your request. The Plan says the surgery is 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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation in the case file does not support that the enrollee has at least one co-morbidity related to obesity.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) (CPT code 43775), for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (Pembrolizumab).

You asked the Plan to pre-approve Keytruda. You say that the drug is medically necessary. The Plan denied
your request. The Plan says that the drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the
drug is medically necessary. Our physician reviewer found this drug is FDA approved for the enrollee's
diagnosis and the documentation supports that the drug is safe and effective for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve
Keytruda (Pembrolizumab).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on March 31, 2021.
You asked the Plan to pay for a periodic oral evaluation, and a teeth cleaning. You say that you disagree with the Plan not paying for these services. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on March 31, 2021.
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 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 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 you do not qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are
consistently ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with
minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of your condition. At this point, your care needs, as a practical matter, can be provided at a lower
level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee 
indicates that the enrollee has chronic low back pain and spinal stenosis with neurogenic claudication. The 
record indicates that imaging has demonstrated severe spinal stenosis at L4-L5, the level requested for 
treatment.  The elements of the coverage criteria are not satisfied.  The requested service cannot be 
recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive one of the copayments charged for dermatology services provided on 
May 4, 2021. 
 
You asked the Plan to waive one of the copayments charged for the dermatology services. You say that the 
enrollee should only have one copayment from this date of service. The Plan denied your request. The Plan 
says that it received two different claims from different dermatology providers on this date, so two copayments 
should apply. 
 
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 Plan contract explicitly states that members pay a $45 for each 
specialist visit.  The medical records in this case clearly state that the two providers that billed services on this 
date of service saw the patient together. As a result of this information, it is clear that only one visit occurred.  
The Evidence of Coverage states that the copayments for specialist services apply on a per-visit basis, not on a 
per-provider basis.  Because these services occurred during the same visit, it is only appropriate that one 
copayment apply. Therefore, we decided that the Plan has to waive one of the copayments charged for 
dermatology services provided on May 4, 2021.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an OON provider.
You asked the Plan to pre-approve physician services. You say that you would like approval to provide these services. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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
physician services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on February 9, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that you were not aware the provider was
out-of-network. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on February
9, 2021 by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy (91110).
You asked the Plan to pre-approve wireless capsule endoscopy. You say that the medical records provided will
show proof of medical necessity. The Plan denied your request. The Plan says capsule endoscopy is considered
experimental and investigational and therefore considered not medically necessary for Crohn's disease
management.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have
to pre-approve wireless capsule endoscopy (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug and does not have to waive the copayment for the administration provided on April 1, 2021.

You asked the Plan to waive the coinsurance for a Medicare Part B drug and to waive the copayment for the administration. You say that you have never been charged a copayment in the past for the injections and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20%
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $50 copayment for specialist visits. 

You received a Medicare Part B drug on April 1, 2021. The total allowed amount is $12 and 20% of that is $2.40. 

You received the administration of Medicare Part B drugs on April 1, 2021. Therefore, you are responsible to pay the $50 copayment. 

The total amount you owe is: $52.40. 

You have been asked to pay the total amount of $52.40 for a Medicare Part B drug and for the administration. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. The administration falls within the physician/practitioner services, including doctor's office visits 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 a Medicare Part B drug and does not have to waive the copayment for the administration provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on October 1, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug testing (80307) rendered by the out-of-network (OON) provider on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99443),
the prolonged evaluation and management service before and/or after direct patient care; first hour (99358),
and the prolonged evaluation and management service before and/or after direct patient care; each additional 30
minutes (99359) rendered by the out-of-network (OON) provider on March 31, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 telephone evaluation and management service (99443), the prolonged
evaluation and management service before and/or after direct patient care; first hour (99358), and the
prolonged evaluation and management service before and/or after direct patient care; each additional 30
minutes (99359) rendered by the out-of-network (OON) provider on March 31, 2021.