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

We decided that the Plan does not have to pre-approve longterm acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.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: Unfavorable

We decided that the Plan does not have to reduce the copayments forthe physical therapy visits provided from February3, 2020 to March 13, 2020.You asked the Plan to reduce the copayments forthe physical therapy visits. You say that you should only be charged a $25 copayment because that is the amount you were quoted.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 $40 copayment for physical therapy at an in-network outpatient hospital. For certain dates of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $40 copayment for physical therapyin an in-network outpatient hospital.You have been asked to pay a $40 copayment for 13 of the physical therapy visits. ($40 x 13 = $520). You have also been asked to pay $14.35 on February 6, 2020 and February 10, 2020. ($14.35 x 2 = $28.70). You have also been asked to pay $27.46 on February 14, 2020 and $17.88 on February 26, 2020. ($520 + $28.70 + $27.46 + $17.88 = $594.04). The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows you were billed by an in-network outpatient hospital 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 forthe physical therapy visits provided by from February 3, 2020 to March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from February 4, 2020 to February 11, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 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 physician's services provided from February 4, 2020 to February 11, 2020.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently in an acute care setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Tadalafil for the enrollee.
Benefits for this drug 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breath test.You asked the Plan to pre-approve a breath test. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested service is not medically necessary.The Plan follows Medicare rules. Medicare rules say that breath analysistests are only covered for certain indications.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 breath test. Our reviewer says that the documentation does not support that the requested breath test is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee's symptoms are classic for SIBO (small intestinal bacterialovergrowth), nor has this diagnosis been identified when previously tested by breath analysis. The enrollee does not meet criteria for the requested 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 a breath test have not been met. Therefore, we decided that the Plan does not have to pre-approve a breath test.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you believe the services should be covered. You say that 911 was called because your family was worried that you were having a stroke. You stated that you weren't transported by the responders and you were not aware that you would be charged.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 13, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea low dose CT scan.You asked the Plan to pre-approvea low dose CT scan. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says you do not meet criteria for the requested services.The Plan must follow Medicare rules. Medicare rules say that low dose CT scans are only covered enrollees ages 55 to 77. We looked at the file and Medicare rules.Review of the file shows that you are currently 51 years old. Based on this information, we decided that Medicare rules for coverage of a low dose CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea low dose CT scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe exercise classes (S9451) provided January 8, 2019 through June 3, 2019.You asked the Plan to pay forthe exercise classes. You say that since the plan had paid for some of your therapy costs immediately before/after surgery, you feel this has been a great heap in keeping you moving freely without pain.The Plan denied your request. The Plan says the plan covers membership for SilverSneakers Fitness program through in-network fitness centers.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For thatreason, the Plan's coverage rules apply in this case. The Plan covers fitness benefits only when you participate in a SilverSneakers fitness program through network fitness centers.The Plan's rules for coverage of gym benefits have not been met because the Fitness program benefit is covered only when provided from an in-network fitness center.Therefore, we decided that the Plan does not have to pay forthe exercise classes (S9451) provided January 8, 2019 through June 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on August 20, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRuxience.You asked the Plan to pre-approvethese services. 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of Wegner's granulomatosis with renal involvement. 1,000 milligrams of Ruxience weekly for four weeks is requested. The Medicare-approved compendia does not support the requested regimen. The requested services are therefore not reasonable or 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-approveRuxience.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEntyvio (J3380) at a dosage of 300 mg every 4 weeks for 1 year.You asked the Plan to pre-approvethe higher dosage of Entyvio. You say that the increased dosage is medically necessary.The Plan denied your request. The Plan says while the Entyvio is medically necessary, the dosage that has been approved is 300 mg every 8 weeks for 1 year. An increased dosage is not medically appropriate.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 higher dosage of Entyvio. Our reviewer says that the increased dosage is not medically necessary. Our physician reviewer found the enrollee's records do not objectively support significant disease activity. Subjective symptoms as described does not necessarily equate to loss of drug response, nor warrant as medically necessary Entyvio dose being doubled.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 higher dosage of Entyvio have not been met.Therefore, we decided that the Plandoes not have to pre-approveEntyvio (J3380) at a dosage of 300 mg every 4 weeks for 1 year.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visit and the emergency room visit provided on November 20, 2019.You asked the Plan to waive the copayments for the urgent care visit and the emergency room visit. You say that you should not be responsible for the copayments. 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 $50 copayment for each in-and out-of-network Medicare-covered urgent care provider visit and a $75 copayment for each in-and out-of-service area Medicare-covered emergency room visit. You have been asked to pay a $50 copayment for the urgent care visit and a $75 copayment for the emergency room visit. The urgent care visit falls within the "Urgently needed services" benefit category. The emergency room visit falls within the "Emergency 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 copayments for the urgent care visit and the emergency room visit provided on November 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care (G0299, G0300). You asked the Plan to pre-approve home health care. You say that the enrollee needs these services.The Plan denied your request. The Plan says these services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health care. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The patient's conditions are chronic and stable.She has had education on her disease management. She has no complex wound care or new enteral feedings or other skilled nursing 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 home health care have not been met.Therefore, we decided that the Plan does not have to pre-approve home health care (G0299, G0300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from January 1, 2020 through January 31, 2020.You asked the Plan to pay forinpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient mental health care. Our physician reviewer found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self or others but was compliant with their treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as the enrollee was not a danger to themselves 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.Our doctor did not find an individualized treatment plan;however,the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 1, 2020 forward as this patient was not shown to be a danger to themselves or others The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.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 pay forinpatient mental health care provided to the enrollee from January 1, 2020 through January 31, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that long term acute care hospital services are medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of a long term acute care hospital admission.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 that you are currently undergoing treatment at an acute care hospital (ACH) for pneumonia. You presented with a tracheotomy and were placed on a ventilator. You are tolerating periods off the ventilator. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services arerequired. You can then be transferred/discharged to a lower level of care for any ongoing long term care 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-approvelong-term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lower extremity ultrasound (93925) provided on February 14, 2020.You asked the Plan to waive the copayment for a lower extremity ultrasound. You say that you believe this was billed incorrectly.The Plan denied your request. The Plan says this processed 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 $25 copayment for carotid or peripheral vascular ultrasounds. You have been asked to pay a $25 copayment for a lower extremity ultrasound. 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 lower extremity ultrasound (93925) provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visits (99337, 1123F, G9744, G8482) provided on December 18, 2019 to December 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON domiciliary or rest home visits. You say that these services were medically necessary.The Plan denied your request. The Plan says these 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 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 domiciliary or rest home visits (99337, 1123F, G9744, G8482) provided on December 18, 2019 to December 23, 2019 by an out of network (OON) provider.