Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on July 13, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that this was a post-operative visit and you disagree with 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 $35 copayment per specialist visit. You had a specialist visit on July 13, 2020. Post-operative visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on July 13, 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 is medically necessary.The Plan denied your request. The Plan says step therapy requirements 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 of Prolia have not been met. Our physician reviewer found the Plan requires either a history of osteoporosis-related fracture OR a trial of drug zoledronic acid before they will approve the requested drug.  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 or have adverse effects for the enrollee.
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. You say that you need to be in rehab for physical therapy. The Plan denied your request. The Plan says your underlying medical conditions are stable, you are at home, and do not require close medical supervision or titration of the medications you normally take by mouth.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do require physical therapy and occupational therapy services, but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Our physician reviewer also found that there is no documentation that you require the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens, polarization, and lens polycarbonate (V2781, V2762, V2784) provided on February 5, 2020.
You asked the Plan to pay for the progressive lens, polarization, and lens polycarbonate. You say that you believe one pair of eyeglasses with standard frames is covered. The Plan denied your request. The Plan says these services are not eligible for coverage.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed after a cataract surgery. We looked at the file and the Plan's rules. You are requesting reimbursement for benefits that are "add ons" to the Medicare-covered standard glasses. These features will not be covered as they are not considered Medicare-covered standard glasses.
Based on this information, we decided that the Plan's rules for coverage of the progressive lens, polarization, and lens polycarbonate have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens, polarization, and lens polycarbonate (V2781, V2762, V2784) provided on February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower level of 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveMVASI.You asked the  Plan to pre-approvethese  services.  You  say that you  disagree  with  the  denial.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 progressive  platinum-resistant  ovarian  cancer.  The  requested  use  of MVASI  with  Keytruda  and cyclophosphamide  is not  FDA-approved  or supported  by Medicare  compendia.  The  submitted  documentation  does not  support  that  the drug safe  and effective  for  the enrollee  or reasonable  and  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-approveMVASI.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF services for the enrollee.
You asked the Plan to pre-approve IRF services for the enrollee. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Medicare coverage criteria for IRF services are not met.
The Plan follows Medicare rules. Medicare has specific coverage criteria for IRF care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules. Our reviewer says that based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an IRF level of care. The medical records provided do not show the enrollee requires an intensive inpatient rehabilitation therapy program. The records show there is concern the enrollee will not be able to fully participate in and benefit from an IRF program. Medicare coverage criteria are 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 IRF services are not met. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation facility services (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: SNF
Decision: Unfavorable

e decided  that  the  Plan  does not  have to pre-approve  SNF services.You asked the  Plan  to pre-approve  the SNF services. The  Plan  denied  your  request.  The  Plan  says that the enrollee  does not meet  Medicare  criteria  for  SNF care.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  the SNF services.  Our reviewer  says that  daily  skilled  services  are not medically necessary.  Our physician  reviewer  found based on the medical records provided  there  is  documentation  that  the enrollee  requires  skilled  nursing  services(intravenous antibiotics),  i.e.,  the specialized  skill,  knowledge  and judgment  of a skilled  professional  nurse  is required  to safely  and effectively  provide  medically  necessary  and reasonable  treatment.  Based on the  medical  records provided  this  enrollee does not require  skilled  therapy  services,  i.e.,  the specialized  skill,  knowledge  and judgment  of  a qualified  therapist  is  not required  to safely  and effectively  provide  medically  necessary  and reasonable  treatment.  Based on the  medical  records provided  daily  skilled  services  (intravenous  antibiotics)  are required.Based on the  medical  records provided  this  enrollee  does not require  the services  on an inpatient basis,  only  in  a skilled  nursing  facility  setting.There  is  no documentation  that  the services  could  not be provided  at a lower  level  of care in  the long-term  care facility.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  SNF services  have  not been  met.Therefore,  we decided  that  the  Plan  does not have  to pre-approve SNF services
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 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 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 you were admitted for treatment of recurrent pleural effusion. The documentation supports that your medical problems are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program provided in an IRF. Your care needs can be met at a lower level of 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.
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 you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medicallynecessary, 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 topre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include intravenous antibiotics, surveillance laboratory studies, woundcare, wound vacuum care, and therapy services. 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approvelong-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on July 8, 2020.You asked the Plan to pay forthe orthoses. You say that the enrollee should not be required to see a specific physician for provided pain management.The Plan denied your request. The Plan says there is no record of the enrollee being treated by the referring provider.The Plan must follow Medicare rules. Medicare rules say that the medical record must contain sufficient documentation of the medical condition to substantiate the necessity for the type and quantity of items orderedWe looked at the file and Medicare rules. The records show that the referring provided is located 2 hours from the enrollee. The documentation does not show that the enrollee received a face-to-face encounter. A review of the file does not show that the serviceswereprovided in an authorized originating site. Consequently, the itemsordered following the non-covered visit are likewise non-covered. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided on July 8, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a continuous glucose monitor system.
You asked the Plan to provide a continuous glucose monitor system. You say that the enrollee needs a CGM. The Plan denied your request. The Plan says the enrollee does not adjust insulin dosage based upon readings as required by Medicare.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor system have not been met. Therefore, we decided that the Plan does not have to provide a continuous glucose monitor system.
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 disagree with the denial. 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 requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 24, 2020 after a fall with resulting hip fracture. He underwent surgical repair on November 29, 2020. The physical therapy note dated December 8, 2020 states he needs minimal assistance with sitting up and stand-by assist to walk 80 feet with a rolling walker. He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 16, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you did not request the ambulance. 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train-of-four (TOF) testing provided on May 26, 2020 billed with code 95999.You asked the Plan to pay forthe TOF testing. You say that all billed codes should be paid.The Plan denied your request. The Plan says Medicare does not make separate payment for TOF testing.The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code.In this case, TOF testing is an integral part of intraoperative neuromonitoring and is considered a component of the comprehensive code. Since this comprehensive code was paid, no separate payment can be made for the single component, TOF testing.Therefore, we decided that the Plan does not have topay forthe train-of-four (TOF) testing provided on May 26, 2020 billed with code 95999.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have a history of irregular heartbeat (paroxysmal atrial fibrillation) monitored by an implanted loop recorder for the last three years without anticoagulation therapy. In this circumstance, ongoing surveillance with an additional loop recorder is not the standard of care and is not 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-approve a subcutaneous cardiac rhythm monitor.