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

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that these services are 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 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 pre-approve skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. The records do not show a need for skilled nursing or skilled therapy services on a daily basis. Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that SNF services are 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 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show that you require skilled nursing or therapy services on a daily basis. Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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 pay for the
drug testing services provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection and the physical therapy visit provided on September 19, 2019 and November 6, 2019.
You asked the Plan to waive the cost share for the injection and the physical therapy visit. You say that you met your maximum out-of-pocket amount. You say the claims should have been paid 100% with zero copayment or coinsurance. 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% of the total cost for in-network Medicare-covered chemotherapy drugs and all other in-network Medicare Part B drugs and a $40 copayment for in-network Medicare-covered physical, language and speech therapy services.
You have been asked to pay a total of $130.69 for the injection and the physical therapy visit. The injection falls within the "Medicare Part B prescription drugs" benefit category. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. The record shows your maximum out-of-pocket amount had not been met at the time of the services. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance/Copayment
Member Liability
September 19, 2019
Injection
$2,067.07
20%
$90.69 - This is less than the standard coinsurance amount.
November 6, 2019
Physical therapy visit
$167.09
$40
$40
Total
$130.69
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 injection and the physical therapy visit provided on September 19, 2019 and November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 13, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 medical services provided to the enrollee by an out-of-network provider on June 13, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 2, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you were approved for the scan and are being asked to pay the full allowed amount. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for CT scans. You have been asked to pay the allowed amount of $167.19, which is less than the $175 copayment for a CT scan. A 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 a CT scan provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G custom myoelectric upper extremity orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says it is an experimental/investigational device and therefore denied. .
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The device is currently considered experimental and investigational. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G custom myoelectric upper extremity orthosis (L8702).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test (78452).
You asked the Plan to pre-approve a nuclear stress test. You say that this is necessary due to your heart murmur and high blood pressure. The Plan denied your request. The Plan says you do not have new symptoms.
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by Medicare. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a nuclear stress test. Our reviewer says that the requested test is not medically necessary. Our physician reviewer found based on the submitted medical records, you have some coronary risk, a heart murmur and no symptoms suggestive of coronary ischemia. In this circumstance stress testing is not considered appropriate by current guidelines. Screening stress testing even in high risk patients has not been shown to improve outcomes. There is no documented covered indication for the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a nuclear stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve a nuclear stress test (78452).
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 the Synvisc-One. You say that you would like reconsideration because the
requested drug is medically necessary. The Plan denied your request. The Plan says the member does no meet
step therapy exception 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 the Synvisc-One. Our reviewer says
that the health plan requires that other forms of hyaluronic acid injections be used. There is no evidence that the
enrollee is allergic to or intolerant of these other forms of hyaluronic acid. Our physician reviewer found there
is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections.
There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and
effective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Synvisc-One have not been met. Therefore, we decided that the Plan does
not have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis (L1833). You asked the Plan to pay for the orthosis. You say that you require the brace. The Plan denied your request. The Plan says the device is not covered if there is no indication of knee instability or recent injury to the knee. The Plan must follow Medicare rules. Medicare rules say that a knee brace is only covered that there is recent injury to the knee or a surgical procedure. A review of the file does not show any objective findings of knee instability or recent injury or surgical procedures to the knee. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that you require the device. The
Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic
pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
(E0652).
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 you would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says the member can safely receive
the services needed in other settings.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do nt
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's
rehabilitation needs can be met at a lower intensity setting.
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: 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. The Plan denied your request. The Plan says the enrollee is not stable for discharge at this time. 
 
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 physician reviewer found that the enrollee was admitted to the acute hospital with suspected NSTEMI, new onset atrial fibrillation, acute new onset systolic heart failure, acute kidney insufficiency, UTI, and encephalopathy. He was treated with antibiotics, metoprolol, heparin, insulin, warfarin, and Bumex. He has required dialysis and tube feeds during his stay. His course was complicated by a stroke. It was noted that the enrollee was gradually improving, becoming more alert but still requiring acute care, monitoring, dialysis, adjustments in blood pressure and diabetes medications, and physical therapy. He does not require services at the proposed LTACH that are not already available at the current acute care hospital. Although he requires additional acute care services, it is not clear that the enrollee would likely require these services for at least 25 days. Therefore, this request for LTACH services will be considered not 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 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT) for basal cell carcinoma.
You asked the Plan to pre-approve the requested IGRT. You say that this is medically necessary for this patient's cancer due to needing to use higher doses per session. The Plan denied your request. The Plan says that daily imaging is neither necessary nor useful when treating with electron beam, ELS, or skin surface brachytherapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 requested IGRT. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found image guided radiotherapy (IGRT) is a means of using of using daily image guidance to help localize the target so as to minimize normal tissue dosing. IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. IGRT images can be obtained prior to treatment on a daily basis or weekly basis. Usually, IGRT is used when critical structures are abutting or in close proximity to the target that is being treated to high doses. As this patient is receiving high dose radiotherapy and high-dose per treatment, and the target is in a location that is not well visualized with the patient in the treatment position (i.e not treated with en face electrons). it is plausible that IGRT would help assure accurate set-up accuracy. A 3D conformal treatment was offered; presumably the patient was immobilized in a mask. The clinical records suggest the need to use bony anatomy to assure accurate positioning. This is plausible and would be within accepted standards of care. As such, this request is medically reasonable and 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 the requested IGRT have been met. Therefore, we decided that the Plan has to pre-approve image-guided radiation therapy (IGRT) for basal cell carcinoma.
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 IRF admission is medically necessary for the
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found 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's
current medical condition does not require intensive physician and nursing oversight in an IRF. The enrollee
does not require this therapy on an intensive level 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 27, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided on June 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on October 25, 2019. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that this should be considered a mammogram screening and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic radiology. 
 
You received a breast ultrasound on October 25, 2019. A breast ultrasound is not considered as part of breast cancer screening. Therefore, you are responsible to pay the $100 copayment.   
 
You have been asked to pay a $100 copayment for a breast ultrasound. A breast ultrasound 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 a breast ultrasound provided on October 25, 2019.