Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided from June 1, 2019 through June 19, 2019.You asked the Plan to waive the copayment forSNF care. You say that you were not told that you were to have a copayment.The Plandenied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You have a $0 copayment each day for days 1 to 19, which member received from May 13, 2019 through May 31, 2019; which was the first 19 days in which you were not assessed a cost share for these dates. Your first day June 01, 2019 was the 20th day at $0 copayment and the Plan started assessing you a copayment on June 2, 2019 through June 19, 2019 which calculated to 18 days X $160 = $2,280. Per you plan benefits the claim processed correctly assessing the $2,280 copayment to member responsibility. 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 forSNF care provided from June 1, 2019 through June 19, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone for the enrollee.
You asked the Plan to pre-approve Dexamethasone. The Plan denied your request. The Plan says Dexamethasone to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone for the enrollee.
Benefits for Dexamethasone 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot, arch support, removable, premolded, longitudinal/ metatarsal, each (CPT Code L3060) provided on October 1, 2019.
You asked the Plan to pay for foot orthotics. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot, arch support, removable, premolded, longitudinal/ metatarsal, each (CPT Code L3060) provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Synvisc One. Our reviewer says that the documentation does not supportthat the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has had a trial of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc wouldlikely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Synvisc One have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 21, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you would like this claim approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 has network providers available who can provide 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 foran office visit provided on March 21, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva Spr 2.5mcg.
You asked the Plan to pre-approve Spiriva Spr 2.5mcg. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.
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 Spiriva Spr 2.5mcg.
Benefits for Spiriva Spr 2.5mcg 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested SNF care is medically
necessary. The Plan denied your request. The Plan says that the enrollee has not gone 60 days in a row without
skilled SNF services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has confirmed that the enrollee has not been receiving any
skilled level of care services since August 16, 2019. The Plan has confirmed that the enrollee is in a long term
care facility and has not received hospital or skilled SNF services for 60 days in a row. In this case, a review
for a new SNF admission is being requested. The Plan has not provided any documentation in support of their
denial of SNF services. The Plan has not requested or provided any medical records for review in order to
determine if the enrollee meets Medicare criteria for a new SNF admission. It is the Plan's responsibility to
show that its decision to deny coverage is correct. In cases where the Plan has not supplied medical records that
are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable.
Enrollees should not be penalized for a Plan's failure to request and obtain medical records. Therefore, we
decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the CT scan and the MRIs provided on
April 18, 2019 and May 7, 2019.
You asked the Plan to reduce the copayments for the CT scan and the MRIs. You say that you were told there
would be a $40 copayment. You say you live on a limited income and would never have received the services
if you knew the copayments would be $190 each. 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 $190
copayment for CT scans performed in an outpatient hospital facility or free standing facility and a $190
copayment for diagnostic radiology other that CT scans performed in an outpatient hospital facility or free
standing facility.
You have been asked to pay a total of $570 for the CT scan and the MRIs. The CT scan and the MRIs fall
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record
shows you received the services at a free standing facility.
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 reduce the copayments for the CT scan and the MRIs provided on April 18, 2019 and
May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 9, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that you should be compensated for the podiatry services rendered to enrollee on August 9, 2019. You believe the services should be considered medically necessary and are requesting reconsideration. The Plan denied your request. The Plan says services provided by non-participating providers are excluded.
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 has network providers available who can provide 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 an office visit (99213) provided on August 9, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. 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 inpatient
mental health care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer
found based on the medical records, the enrollee did not appear to require inpatient mental health treatment
beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual
hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place
beyond the date in question. It did not appear that the services were reasonably expected to improve the
patient's condition or for the purpose of diagnosis beyond the date in question. There is no individualized
treatment plan. Based upon review the records the enrollee does not meet the criteria for continued acute
inpatient mental health treatment for the dates in question as of January 23, 2020 forward. Medicare coverage
criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care 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. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the member does not meet criteria for admission to an IRF.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 reviewerto 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 necessarybased on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an inpatient stay with an interdisciplinary approach to rehabilitationcare. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93925) provided on May 2, 2019 by out of network provider.
You asked the Plan to pay for a duplex scan. You say that you are requesting that the claim be reprocessed for payment. The Plan denied your request. The Plan says the non-urgent service was not authorized because a non-network provider who does not work with the Plan. A non-network provider, referred the member. The member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 duplex scan (93925) provided on May 2, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that you had surgery with this provider. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 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 medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), ankle foot orthosis (L1971), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on July 25, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), ankle foot orthosis (L1971), lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on July 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 9, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a valid physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on 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 provided on September 9, 2019.
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 for the enrollee.
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 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 had an acute hospital stay from November 26, 2019 to December 18, 2019 and was discharged to a skilled nursing facility (SNF). The enrollee was discharged from the SNF on January 12, 2020. She needs minimal to contact guard assist with most activities of daily living and transfers. She has no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not show that she would be able to fully participate in and benefit from 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 the enrollee's deconditioning would be
best managed in the LTACH setting. The Plan denied your request. The Plan says there is no service that can
be provided at the LTACH that is clinically better than those provided in the current facility regardless of how
long the admission is.
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 patient is currently undergoing treatment at an ACH for sepsis and bacteremia
attributed to an ICD pocket infection. The enrollee has received antibiotics and had his ICD exchanged. The
enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there
is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until
such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of
care for any ongoing LTC needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.