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

We decided that the Plan does not have to pre-approve Regranex Gel for the enrollee.
You asked the Plan to pre-approve Regranex Gel under Medicare Part B. You say that this drug is medically necessary. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare 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 Regranex Gel for the enrollee.
Benefits for Regranex Gel 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: Drugs
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this care is medically necessary. The
Plan denied your request. The Plan says that the enrollee has not yet completed the full course of care in the
hospital.
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 services is not considered medically reasonable and necessary in this case. The
patient is currently under the appropriate level of care. It is not clear that 25 days will be required at LTACH.
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH
services.
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 for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve gastrointestinal tract imaging (91110).
You asked the Plan to pre-approve the gastrointestinal tract imaging. You say that you would like
reconsideration because this service comes recommended for finding the source of the member's pain. The Plan
denied your request. The Plan says that the use of the wireless capsule endoscopy is considered investigational
as a treatment option for unexplained abdominal pain.
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 gastrointestinal tract imaging. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found the member's condition is a community-accepted indication for capsule
endocopy.
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 gastrointestinal tract imaging have been met. Therefore, we decided that the
Plan has to pre-approve gastrointestinal tract imaging (91110).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on January 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab tests provided on January 24, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heel lift orthotics (L3300 x 2).
You asked the Plan to pre-approve the heel lift orthotics. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit for the enrollee's condition.
Medicare rules state that supportive devices for the feet (such as heel lift orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although heel lift orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of heel lift orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve heel lift orthotics (L3300 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments applied to inpatient hospital services provided on October 11 - October 18 and on October 22 - October 26, 2019.
You asked the Plan to waive the copayments applied to the inpatient hospital services. You say that the enrollee's out of pocket expenses were met in December and that the billing appears to be in error. The Plan denied your request. The Plan says the copayments were appropriately applied to the services in dispute.
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 $285 copayment per day, days 1-7 for inpatient hospital care. The enrollee was asked to pay a $285 copayment per day, days 1-7 for the inpatient hospital services. The inpatient services billed for dates of service October 11 - October 18 were paid with a $1,995 copayment applied. The inpatient services billed for dates of service October 22 - October 26, 2019 were paid with a $855 copayment applied. The inpatient hospital services fall within the inpatient hospital care benefit category. This means that the enrollee was asked to pay the correct amounts based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. The records do not show that the out of pocket maximum for the year was met at the time these claims were processed. Therefore, we decided that the Plan does not have to waive the copayments applied to inpatient hospital services provided on October 11 - October 18 and on October 22 - October 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion imaging (78452) provided on May 20, 2018.
You asked the Plan to pay for myocardial perfusion imaging. You say that this claim was originally filed to Original Medicare. The Plan denied your request. The Plan says this was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for myocardial perfusion imaging was not filed until June 3, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for myocardial perfusion imaging (78452) provided on May 20, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan for the enrollee.
You asked the Plan to pre-approve Xifaxan. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare 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 Xifaxan for the enrollee.
Benefits for Xifaxan 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mental health services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the mental health 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 neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network providers available to you that can provide the care and treatment you are requesting.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the mental health services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bariatric shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bariatric shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cordran for the enrollee.
You asked the Plan to pre-approve Cordran. You say that Cordran is medically necessary. The Plan denied your request. The Plan says this self-administered drug is not covered under Medicare 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 Cordran for the enrollee.
Benefits for Cordran 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The
Plan denied your request. The Plan says the enrollee does not meet criteria for Orthovisc.
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 Orthovisc. Our reviewer says that the
enrollee does not meet criteria for Orthovisc. Our physician reviewer found the enrollee has osteoarthritis of the
knee. Review of the documentation does not support the above guidelines have been met. There is no
radiographic evidence of osteoarthritis or a trial of three months of conservative therapy. Without the support
of the documentation, Medicare 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orthovisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require prolonged care at the acute level and should be treated at an LTACH. The Plan denied your request. The Plan says the enrollee is receiving adequate care and LTACH is not clinically superior to the current facility.
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 has chronic respiratory failure on a ventilator and is in the ICU with complex wounds and no progress on vent weaning. The enrollee is current not able to get PEG tube placed due to abdominal wounds. At present, it appears the enrollee is at the appropriate level of care. Several issues need to be addressed, particularly feeding, before moving forward to LTACH level of care. Nasogastric feeding typically not a good long term solution. LTACH care is not medically reasonable 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140) provided on March 10, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because you had this same service done on January 30, 2020. Your EOC states, limited exam to evaluate a problem (D0140) is covered one (1) procedure per plan year. Therefore, we decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140) provided on March 10, 2020 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of continued inpatient skilled nursing facility 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 SNF care. Our reviewer says that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the 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 continued inpatient skilled nursing facility (SNF) care.
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 are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 appears to be stable enough to discharge to a lower level of care soon. The enrollee does not require services at the proposed LTACH that are not already available at the current acute 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography (TTE) (93306).
You asked the Plan to pre-approve transthoracic echocardiography. You say that this is necessary for a followup
of mitral regurgitation. The Plan denied your request. The Plan says that the enrollee has no new symptoms
to warrant repeat echocardiogram.
The Plan follows Medicare rules. Medicare rules say that TTE is covered only when medically necessary per
the above listed guidelines.
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 transthoracic echocardiography. Our
reviewer says that the criteria for coverage of TTE has been met. Our physician reviewer found the patient has
moderate-severe mitral regurgitation and cardiomyopathy with decreased left ventricle function. With regard
to the need for repeat TTE within one year of the last one, his symptoms have improved due to lifestyle and
dietary changes with significant weight loss. This can improve loading conditions on the heart and decrease
mitral insufficiency. If the patient still had severe mitral insufficiency with some left ventricle dysfunction on
transthoracic study, then the plan was for further evaluation of the mitral regurgitation severity by transesophageal
echocardiography study before consideration of mitral percutaneous or surgical repair. Therefore,
repeat assessment of the severity of the mitral regurgitation now that loading conditions have changed and the
patient's clinical status has improved is reasonable and medically indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transthoracic echocardiography have been met. Therefore, we decided that the
Plan has to pre-approve transthoracic echocardiography (TTE) (93306).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF care. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the requested continuation of SNF care does not meet criteria.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before July 9, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.