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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically appropriate. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.
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 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 he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided on July 1, 2020 to July 31, 2020.
You asked the Plan to pay for the services provided. You say that life-sustaining dialysis services were provided to the enrollee. The Plan denied your request. The Plan says payment cannot be made because of the inactive and closed rate record.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says you receive your care from a provider who is eligible to provide services under Original Medicare. The requested provider in this case is not a network provider with the Plan, or eligible to provide services under Original Medicare. The Plan had network providers available to 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 dialysis services provided on July 1, 2020 to July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine hearing aid fitting and comprehensive hearing test provided to the enrollee on December 18, 2019, by an out-of-network provider.
You asked the Plan to pay for the hearing services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you received these services by an out-of-network provider within the enrollee's service area. The Plan states the enrollee's needs could have been met by an in-network provider and the enrollee's needs were not urgent or emergent.
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 a routine hearing aid fitting and comprehensive hearing test provided to the enrollee on December 18, 2019, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided on August 24, 2020.
You asked the Plan to pay for treatment of root canal obstruction. You say that you do not understand why payment was denied for the service. The Plan denied your request. The Plan says treatment of root canal obstruction is not listed as a covered dental service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided on August 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG).
You asked the Plan to pre-approve IVIG. You say that the requested IVIG is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested IVIG.
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 IVIG. Our reviewer says that the enrollee does not meet criteria for the requested IVIG. Our physician reviewer found the enrollee is with leg weakness due to muscle damage following C4-C6 laminectomy. During further evaluation she was found to be B12 and folate deficient and to have immune necrotizing myositis. The request is for continued IVIG therapy. In this case, the enrollee has immune necrotizing myositis. This diagnosis is not a covered indication under the local coverage determination. Therefore, 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 IVIG have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care and advance care planning provided on February 13, 2020. You asked the Plan to pay for the initial hospital care and advance care planning. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 8, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care and advance care planning provided on February 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on September 17, 2020.
You asked the Plan to pay for the physician services. You say that you have received bills for denied claims. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on September 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Prolia. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has osteoporosis. The documentation does not support that the enrollee has tried and failed zoledronic acid. There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amiodarone Hydrochloride.
You asked the Plan to pre-approve Amiodarone Hydrochloride. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Amiodarone Hydrochloride.
Benefits for Amiodarone Hydrochloride 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus surgery for the enrollee.
You asked the Plan to pre-approve sinus surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.
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 sinus surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records show the enrollee has not been diagnosed with chronic sinusitis which is defined as a sinus infection lasted 12 continuous weeks or at least 4 infections in a year. Also, it is not documented if the enrollee has consistently been on steroid nasal sprays, sinus rinses, and multiple courses of sinusitis appropriate antibiotics. Finally, and most significantly, the CT scan does not show evidence of obstructive sinus disease. The imaging scan shows a few areas of minimal mucosal thickening. The literature and the Academy of Otolaryngology does not support using balloon sinuplasty in the setting of imaging that does not show significant chronic sinusitis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sinus surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve sinus surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital on January 6, 2020, to June 16, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you had stents changed out. You say that this is way too much. 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 $395 copayment for outpatient surgery/outpatient hospital. You have been asked to pay a $395 copayment for each outpatient surgery. The total amount you are being asked to pay is $1,185 ($395 x 3 surgeries = $1,185). An outpatient surgery falls within the outpatient surgery/outpatient hospital 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 an outpatient surgery provided by a participating hospital on January 6, 2020, to June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the dualenergy X-ray absorptiometry (DXA) bone density study provided on November 5, 2020.
You asked the Plan to pay for the dualenergy X-ray absorptiometry (DXA) bone density study. 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The dualenergy X-ray absorptiometry (DXA) bone density study at issue in this appeal was requested solely for screening purposes. The documentation does not support that the enrollee has any risk factors for osteoporosis to support this testing was not for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the dualenergy X-ray absorptiometry (DXA) bone density study provided on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is non-covered. We looked at the file and Medicare rules. The services at issue are a power seat elevation system for a power wheelchair. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion therapy and its administration provided on April 8, 2020.
You asked the Plan to waive the coinsurance for the infusion therapy and its administration. You say that you feel the enrollee is being overcharged. You say the deductible had been met and the same treatment was given for several months and no balance was due. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug. The enrollee has been asked to pay a total of $2,655.70 which is 20% coinsurance for the infusion therapy and its administration. The infusion therapy and its administration fall within the "Medicare Part B prescription drugs" benefit category. See chart below. Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
April 8, 2020
Chemotherapy administration
$277.63
20%
$55.53
April 8, 2020
Chemotherapy administration
$54.23
20%
$10.85
April 8, 2020
Chemotherapy injection
$7,717.46
20%
$1,543.49
April 8, 2020
Chemotherapy injection
$3,631.74
20%
$726.35
April 8, 2020
Chemotherapy injection
$4,179.77
20%
$319.48 - This is less than the standard amount because you met your maximum out-of-pocket amount.
Total
$2,655.70
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for infusion therapy and its administration provided on April 8, 2020.
Please note, our decision is only regarding the April 8, 2020 services. Please contact the Plan directly about other dates of service.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (G0156) provided from August 24, 2020, to August 28, 2020.
You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied your request. The Plan says the records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes. We find that CPT code G0156 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of home health services being performed. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services (G0156) provided from August 24, 2020, to August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from October 12, 2020, through October 13, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you did not go to the ER twice but were charged $150. You say that you shouldn't pay an extra $75. 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 $150 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room or outpatient surgery services. You have been asked to pay a $150 copayment for the observation stay. The observation stay falls within the "Outpatient Hospital Services" benefit category. The records show you were admitted to outpatient observation. 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 observation stay provided from October 12, 2020, through October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's rehabilitation needs can be met at a lower level of care such as a skilled nursing facility.

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 COVID infection, acute respiratory failure, gastrointestinal bleeding and anemia. The 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 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 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TVEC injection (J9325).
You asked the Plan to pre-approve TVEC. You say that the requested drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is prescribed for a medically unaccepted indication.
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 TVEC. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the requested use of TVEC is not FDA-approved for the enrollee's diagnosis. TVEC is FDA-approved for cutaneous melanoma. The enrollee has squamous cell skin cancer. The use of TVEC for squamous cell skin cancer is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. This use is still the subject of clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TVEC have not been met. Therefore, we decided that the Plan does not have to pre-approve TVEC injection (J9325).