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

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF
admission.

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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for falls, weakness, bradycardia, and acute on chronic congestive heart failure. His medical problems
are stable. There are no complex nursing or rehabilitation needs.

The patient 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.

Additionally, there is not a reasonable expectation that this patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), the periapical x-ray (d0220), core build up (D2950), and the crown (D2740).

You asked the Plan to pay for the dental services. You say that you have been a patient at this dental office for 25 years. You say that the office called your insurance to verify your benefits and then called you back to set up an appointment. You say that you were advised that the cost of the services would be $580.50. You say that you received a bill $781.50. You also say that The Plan denied your request. The Plan says bitewing x-ray is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan says that core build up is not listed as a covered service. The Plan says that crown is not listed as a covered service either.

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 dental services you received are not among those covered under this benefit. The record shows that you did not elect to purchase the optional supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274), the periapical x-ray (d0220), core build up (D2950), and the crown (D2740).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services.

You asked the Plan to pay for the ambulance services. You say that you have always been charged a $250 copay for similar services. The Plan denied your request. The Plan says prior authorization is required for non-emergency transport.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file, and Medicare rules. The records provided show that your lungs were clear, your oxygen levels were within normal limits, and you were able to ambulate with assistance to the gurney. The records do not show that other forms of transportation would endanger your health. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spravato.

You asked the Plan to pre-approve Spravato. You say that the enrollee has failed multiple oral anti-depressants. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.

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 Spravato.

Benefits for Spravato 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation (90791).

You asked the Plan to waive the copayment for the psychiatric evaluation. You say that you were unsatisfied with the level of care provided during the evaluation and feel that you should not be responsible for the copayment. The Plan denied your request. The Plan says this service was provided and the $40 copayment was applied correctly. A quality of care complaint has been filed on your behalf and will be addressed separately.

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 $40 copayment for outpatient mental health care.

You have been asked to pay a $40 copayment for the psychiatric evaluation. You were unsatisfied with the level of care provided, and the Plan has filed a separate complaint with the appropriate entity on your behalf. Maximus Federal Services cannot address quality of care issues.

A psychiatric evaluation falls within the outpatient mental health care 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 psychiatric diagnostic evaluation (90791).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor for the
enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says this 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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the request is for Freestyle Libre continuous glucose monitor to assist in managing his oral medication
regimen. In this case, the enrollee is not on insulin. The elements of the local coverage determination have not
been satisfied.

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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Freestyle Libre continuous glucose monitor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the step therapy guidelines were not followed.

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 the drug. Our physician reviewer found
there is no evidence of a trial and failure of Retacrit. There is no evidence provided that Retacrit would be less
effective and/or likely have adverse effects.

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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pradaxa.

You asked the Plan to pre-approve Pradaxa. You say that the enrollee has been on this medication for 9 years.
The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription
drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Pradaxa.

Benefits for Pradaxa 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for hearing aids (V5261).

You asked the Plan to pay the full cost for hearing aids. You say that your hearing aids should be covered. The Plan denied your request. The Plan says the Plan has paid the maximum benefit for hearing aids.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to a $1,000 allowance for hearing aids. 

We looked at the file and the Plan's rules. The Plan has paid $1,000 for the hearing aids at issue and you are responsible for the remaining cost. Therefore, we decided that the Plan does not have to pay the full cost for hearing aids (V5261).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (EM) services provided in an assisted living facility by an out of network (OON) provider.

You asked the Plan to pay for the OON EM services. You say that you feel that the services should have been approved by the facility. The Plan denied your request. The Plan says these services were provided in a non-emergent situation by an OON provider in an OON facility. Authorization is required for coverage to be allowed.

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 evaluation and management (EM) services provided in an assisted living facility by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing.

You asked the Plan to pay for drug tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the place of service.

We looked at the file and Medicare rules. The documentation submitted does not support that the Place of Service (POS) code 81 is appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care.

You asked the Plan to pay for the post-stabilization care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the inpatient care was unauthorized post-stabilization care.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 post-stabilization care. Our reviewer says that there was no documentation to support that the enrollee was "unstable to transfer." Our physician reviewer found at this time; the enrollee is stable for transfer. All inpatient care provided was not needed on an emergent basis. The post-stabilization care services after were not medically necessary or reasonable. The enrollee was hemodynamically and neurologically stable for ambulance transport with monitoring to a Plan facility. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiogram (93306).

You asked the Plan to pay for the echocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says payment was already issued for 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. 

We find that CPT code 93306 is not supported in the medical record. Specifically, the facility already submitted a global claim for this service and the facility was issued payment for this service. The rendering physician is not eligible for payment on an additional global billing. Based on this information, we decided that Medicare rules for coverage of the echocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an echocardiogram (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no detailed objective neuromuscular assessment of the bilateral upper extremities on the treating nurse practitioner note or a physician progress note indicating reasons why this enrollee is unable to propel a manual wheelchair. The seating and mobility documentation note that the enrollee has limited upper extremity strength and function to use an ambulatory assistive device, but there is no evidence of this in the treating nurse practitioner (NP) progress notes. Furthermore, the NP progress note indicates that the enrollee has dementia and memory impairment, therefore it is not clear that the enrollee could operate the power wheelchair. There is no evidence of spasticity or intermittent catheterization. There is evidence that the enrollee uses a walker and/or cane. It is not clear why the enrollee cannot perform a functional weight shift. The power tilt/recline accessory is not supported. The documentation does not reveal a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee; or significant edema of the lower extremities that requires an elevating leg rest.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance transport services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that the use of the CT scan was my doctor's decision. You say that you should not have to pay. 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 $250 copayment for covered diagnostic radiology services in the outpatient department of a network hospital or facility.

You have been asked to pay $135.78, which is less than the standard $250 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the CT scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laparoscopy.

You asked the Plan to waive the copayment for the laparoscopy. You say that you paid the charge even though you thought you were inpatient at the time. 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 $350 copayment for an outpatient hospital facility.

You have been asked to pay a $350 copayment for the laparoscopy. The laparoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records do not show that you were admitted as an inpatient. 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 laparoscopy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 14 physical therapy (PT) sessions (24 requested in total).

You asked the Plan to pre-approve the additional PT visits. You say that you have seen improvement with the therapy provided thus far. It is felt that additional sessions will allow for continued improvement. The Plan denied your request. The Plan says an additional 10 sessions are allowed, and further visits can be considered after re-evaluation.

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 the additional PT visits. 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 reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy for this condition and the plan approved an additional 10 sessions of therapy. Without the outcome and indication for ongoing skilled therapy at this time, the records do not demonstrate that the unique skills of a professional therapist will be required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist.

The patient can be reassessed at the end of the additional authorized therapy to see if skilled therapy services are still needed. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 14 physical therapy (PT) sessions (24 requested in total).