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

We decided that the Plan does not have to pre-approve swing bed services.
You asked the Plan to pre-approve swing bed services. You say that you would like to go to a swing bed facility rather than a SNF. The Plan denied your request. The Plan says the level of services required can be provided at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 swing bed services. Our reviewer says a swing bed facility is not medically reasonable and necessary. Our physician reviewer found the request to receive subacute rehab (SAR) services in a swing bed, rather than at a SNF, appears to be socially driven. There is no evidence that the use of a swing bed is medically necessary, or availability driven (i.e. no SNF beds available). As such, the request to receive SAR services in a swing bed is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of swing bed services have not been met. Therefore, we decided that the Plan does not have to pre-approve swing bed services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to lower the cost share the destruction of lower or sacral spinal facet
joint nerves using imaging guidance (64635) provided January 15, 2021, by an out-of-network (OON)
provider.

You asked the Plan to lower the cost share the destruction of lower or sacral spinal facet joint nerves using
imaging guidance. You say that you would like the cost share to be reduced to the in-network level. The Plan
denied your request. The Plan says the cost share has processed correctly in this case.

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%
coinsurance for outpatient surgery performed by an OON provider.

You have been asked to pay a total cost share of $340.32 for the destruction of lower or sacral spinal facet joint nerves using imaging guidance ($850.81 Medicare allowed amount x 40% coinsurance). This service falls within the outpatient surgery performed by an OON provider 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 lower the cost share the destruction of lower or sacral spinal facet joint nerves using imaging guidance (64635) provided January 15, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that you need transportation to treatments to stay healthy. The Plan denied your request. The Plan says you have exhausted all of the trips for this year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The records show that you have used 20 trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reclast.

You asked the Plan to pre-approve Reclast. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the coverage criteria for this drug have not been met.

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 Reclast. Our reviewer says that the
requested drug is not medically reasonable and necessary for the enrollee. Our physician reviewer found Per
the reviewed documentation, the enrollee had previous iron deficiency anemia, B12 deficiency, and deep vein
thrombosis. The provider's reasoning for using this injection is to prevent osteoporosis in women who no
longer have monthly periods. The review has determined that the documentation does not support that the
requested Zoledronic acid is medically reasonable or necessary for the patient. The documentation does not
support that the requested Zoledronic acid is safe and effective for the patient

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to
pre-approve Reclast.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation services provided January 20, 2021 to January 30, 2021.
You asked the Plan to pay for the inpatient rehabilitation services. You say that the service should be covered. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible and$300 copayment for inpatient services. The item or service you asked the Plan to pay for falls within the benefit category inpatient services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible and $300 copayment for inpatient services. The deductible was not met the time the services was rendered. This cost sharing is a contractual obligation that had not been met at the time the inpatient rehabilitation services was received on January 20, 2021 to January 30, 2021. Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation services provided January 20, 2021 to January 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete intraoral series of radiographic images (D0210), and caries risk assessment and documentation (D0603) provided on April 7, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, a complete intraoral series of radiographic images, and caries risk assessment and documentation. You say that you thought the provider was in-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a complete intraoral series of radiographic images, and caries risk assessment and documentation have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), a complete intraoral series of radiographic images (D0210), and caries risk assessment and documentation (D0603) provided on April 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 48 additional routine transportation trips.

You asked the Plan to provide 48 additional routine transportation trips. You say that you have doctor appointments and need transportation. The Plan denied your request. The Plan says you have exhausted your routine transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 48 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow.

You asked the Plan to pre-approve fluid flow. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 fluid flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested therapy. The review has determined that items/services at issue in this case are not medically reasonable or 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 fluid flow have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccine (90715, 90472) administered July 13, 2020.
You asked the Plan to pay for the TDAP vaccine. You say that this service should be covered and was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. Therefore, we decided that the Plan does not have to pay for a Tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccine (90715, 90472) administered July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopic colostomy performed by a tertiary care provider.
You asked the Plan to pre-approve the requested services. You say that you finally found a surgeon that has the capacity to correct your issue. The Plan denied your request. The Plan says the documentation does not support the need for tertiary care.
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 requested services. Our physician reviewer found that there is no specific documentation indicating that you require a tertiary level of care for a laparoscopic colostomy procedure. There is no documentation from a primary network provider indicating they are unable to perform the procedure. The review has determined that the records do not indicate that care from a tertiary provider is medically reasonable and necessary to treat your condition.
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 services have not been met.
Therefore, we decided that the Plan does not have to pre-approve a laparoscopic colostomy performed by a tertiary care provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code G0483) provided to the enrollee on August 19, 2020, by an out-of-network provider.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 laboratory services (CPT code G0483) provided to the enrollee on August 19, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on March 21, 2021.
You asked the Plan to waive the copayment for the urgent care services. You say that the office visit never happened. The Plan denied your request. The Plan says you were charged this copayment 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 $65 copayment for Urgently needed services. You have been asked to pay a $65 copayment for the urgent care services. The medical record shows you were seen by a nurse practitioner at an Urgent Care facility. The urgent care services fall within the Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgent care services provided on March 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require close medical supervision or complex rehab needs.

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 physician reviewer found that you were admitted to the acute care hospital for peripheral artery disease and an above the knee amputation. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110), and topical application of fluoride - excluding varnish (D1208) provided February 26, 2020.

You asked the Plan to provide additional payment for the periodic oral exam, bitewing x-rays, intraoral x-rays, dental cleaning and fluoride treatment. You say that you were told the provider was in-network and expected the services to be covered. The Plan denied your request. The Plan says the services have been covered up to the MAC. Since the provider is out-of-network you are responsible for the difference between the MAC and the total cost charged by the provider.

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. The Plan covers the periodic oral exam, bitewing x-rays, intraoral x-rays, dental cleaning and fluoride treatment up to the MAC. 

We looked at the file and Medicare rules. The services in this case were provided by an OON provider. The Plan provided documentation showing that coverage has been provided up to the MAC. You are responsible for costs billed above the MAC. Therefore, we decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110), and topical application of fluoride - excluding varnish (D1208) provided February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the criteria for coverage have not been met in this case. Our physician reviewer found the review indicates that the enrollee is a 77-year-old female diagnosed with osteoporosis. The Plan requires a trial of Zoledronic acid before they will approve the requested drug, Prolia. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture
after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.