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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission iscovered 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 services are not medically necessary. Our physician reviewer found the records show that you have a history of a neck spine fracture in July of 2015 and prior spine surgeries. He is currently receiving outpatient physical therapy. As of February 17, 2020 you need assistance with upper and lower body dressing and are independent with grooming, toileting, and ambulating. You do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to enrollee on November 23, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.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 test at issue in this appeal was requested solely 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 laboratory services rendered to enrollee on November 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF)admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that the enrollee needs inpatient rehab.The Plan denied your request. The Plan says the services are 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 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 29, 2020 with intractable back pain. She was also positive for a urinary tract infection. The complexity of her nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal thatthe enrollee requires the intensity of an IRF stay with close physician or nursing supervision. She may benefit and participate in additional therapy of PT and OT but the patient does not require an intensive 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.You asked the Plan to pre-approve continued physical therapy services. You say that this is necessary because the enrollee is still in pain.The Plan denied your request. The Plan says the enrollee has not had a major response to physical therapy, so continued therapy is unlikely to be effective.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 continued physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewerfound the records from physical therapy show that the enrollee asks to stop the sessions due to pain at almost every session. The enrollee is receiving repetitive, endurance training. He does not have functional limitations that require the unique skills of a therapist. These services are adequate after teaching and educating the patient and can be provided by a personal trainer if needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued physical therapy services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued physical therapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 23, 2019 to July 22, 2019.You asked the Plan to pay for this service. You say that SNF services were medically necessary. The Plan denied your request. The Plan says Medicare criteria for SNF services were not met. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there were no identifiable daily skilled nursing or daily skilled therapy services required by the enrollee at in inpatient SNF level of care during the dates of service in question.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 23, 2019 to July 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer
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 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a long term history of
radicular back pain. He has reportedly failed conservative treatment, including recent medications and
stretching exercise. There is limited indication that he would be indicated for operative treatment at the L3/4
level. Additionally, there is radiographic evidence of diffuse demineralization with no documentation of DEXA
scan findings showing no osteoporosis. The Superion spacer is considered experimental/investigational in
nature and not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Superion spacer
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe external defibrillator from July 1, 2019 to September 1, 2019.You asked the Plan to waive the coinsurance forthe external defibrillator. You say that you should not be responsible for the September charge because you did not use it and the July and August charges should be covered in full because you were not aware of the cost. 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 20% coinsurance per Medicare-covered item. You have been asked to pay $579.90 which is 20% of the allowed amount for each date of service for the external defibrillator. The allowed amount is $2,899.50. ($2,899.50 x 20% = $579.90). The external defibrillator falls within the "Durable medical equipment (DME) and related supplies" 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 forthe external defibrillator provided from July 1, 2019 to September 1, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Euflexxa viscosupplementation injections.You asked the Planto pre-approvethe Euflexxa injections. You say that the enrollee requires this treatment.The Plandenied your request. The Plansaysthere is no reason noted that the plan preferred agents would not be reasonable in this case.Medicare covers Part B medicationswhen 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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Euflexxa injections. Our reviewer says that the requested medication is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The enrollee has not trialed the preferred drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.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 Euflexxa injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEuflexxa viscosupplementation injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the payment for the periodic oral evaluation, prophylaxis, and bitewings provided on October 22, 2019.
You asked the Plan to reduce the payment for the periodic oral evaluation, prophylaxis, and bitewings. You say that the total bill of $124.80 is too high for you to pay. The Plan denied your request. The Plan says these services are not covered under the Plan.
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 reduce the payment for the periodic oral evaluation, prophylaxis, and bitewings provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.You asked the Plan to pre-approve the physician's services to be provided. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 services at issue in this appeal. 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 physician's services to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on August 28, 2019.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. There is no itemized delivery ticket to indicate what specific supplies were provided. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on August 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 2, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were advised that the hospital would cover the ambulance transport between hospitals. 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 a $200 copayment for each one-way Medicare-covered ambulance transport. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" 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 the ambulance ride provided on October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient stay provided from October 13, 2019 through October 15, 2019.You asked the Plan to waive the cost share for the inpatient stay. You say that you were billed for therapy which you never you received. You say the services should be removed from the claim.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan says that you must pay a $250 copayment per in-network admission after the deductible is met.The item or service you asked the Plan to waive the cost share for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,250 deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient stay was received from October 13, 2019 to October 15, 2019.Therefore, $1,250 was applied to your deductible. Since you met your $1,250 deductible, you have also been asked to pay a $250 copayment. The records show that you were an inpatient for two days. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the inpatient stay provided from October 13, 2019 through October 15, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the left knee. The records do not show that he has tried and failed the plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be less effective or contraindicated; therefore, Genvisc is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate mandibular denture, immediate maxillary denture, extraction, and alveoloplasty in conjunction with extractions provided on August 27, 2018.
You asked the Plan to pay for the immediate mandibular and maxillary dentures, extraction, and alveoloplasty. You say that dentures, radiographic images, and extractions are covered according to your benefits. The Plan denied your request. The Plan says your plan excludes these services.
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 the immediate mandibular denture, immediate maxillary denture, extraction, and alveoloplasty in conjunction with extractions provided on August 27, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the member developed a bleed that required transfusion over the course of 2 days. The Plan denied your request. The Plan says that there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intensive level.
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 member has multiple complex medical conditions and physician supervision at an acute rehabilitation level of care is required. Our physician reviewer found the member requires physical therapy for mobility, occupational therapy for remaining activities of daily living and adaptive equipment, and speech therapy for dysphagia, dysarthria, cognition, and communication. Care at a lower level would not effectively meet his rehabilitation 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 IRF care have been met. Therefore, we decided that the Plan has 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 pay forservices provided by provider on August 6, 2019.You asked the Plan to pay forthe ambulatory surgical services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says unlisted procedure codes are not payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that  Based on this information, we decided that Medicare rules for coverage of the ambulatory surgical services have not been met.Therefore, we decided that the Plan does not have to pay forservices provided by provider on August 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the enrollee.You asked the Plan to pre-approvethese services. You say that the enrollee needs skilled nursing.The Plan denied your request. The Plan says the admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factorslisted above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 16, 2020 and received oral medications. She had stable vital signs and had increasing oxygen needs. She needs contact guard to minimal assist with functional mobility and needs varied assist with activities of daily living. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the enrollee.