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

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH care would be most appropriate for the enrollee's treatment. The Plan denied your request. The Plan says the enrollee's needs are being met in 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 a history of inclusion body myositis and was admitted to the acute care hospital on July 16, 2021 with respiratory failure. On July 21, 2021, a tracheostomy and a feeding tube were placed. On July 27, 2021, the enrollee remained critically ill. 

Long-term acute care hospitals (LTACHs) are certified as acute care hospitals, and generally do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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. 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-approve LTACH services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Lucentis.

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 that the step therapy requirement is not 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of bilateral proliferative diabetic retinopathy with macular edema. Although the Plan requires failed treatment with Avastin or Mvasi prior to approval of Lucentis, the required drug is unavailable due to a national shortage. Time is of the essence when dealing with active macular edema and proliferative diabetic retinopathy and delay of treatment puts the enrollee's sight at undue risk. Mvsai is not FDA-approved for the treatment of diabetic retinopathy. Medical studies demonstrate that ranibizumab is as effective as bevacizumab for the enrollee's condition. There are no other generic alternatives with equal efficacy. The requested Lucentis is therefore reasonable and medically necessary at this time, as it is not reasonable or safe to adhere to the step therapy protocol. 

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 been met. Therefore, we decided that the Plan has to pre-approve Lucentis.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on January 27, 2021.

You asked the Plan to pay for a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning. You say that you were not aware that you were not enrolled in the supplemental dental plan. The Plan denied your request. The Plan says you were not enrolled with the additional supplemental benefit on the date of service.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 12, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 12, 2021.
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 are not able to walk, and you need IRF care to be able to walk again. The Plan denied your request. The Plan says you require physical and occupational therapy, but your needs can be met in another setting besides in an IRF.

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.

Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis and colitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test provided by a participating provider on March 3, 2021.

You asked the Plan to waive the copayment for a diagnostic test. You say that you are being charged incorrectly. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $5 copayment for outpatient diagnostic tests/diagnostic tests. 

You have been asked to pay a $5 copayment for a diagnostic test. The correct copayment has been applied to the diagnostic test that was provided. A diagnostic test falls within the outpatient diagnostic tests/diagnostic tests benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic test provided by a participating provider on March 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the enrollee underwent surgery and now needs physical and occupational therapy to be able to get out of bed and sit in a wheelchair. You say that, without this therapy, the enrollee's physician has stated that she is likely to develop pneumonia and could die. You say that the medical records provided demonstrate the medical necessity of SNF care. The Plan denied your request. The Plan says the clinical information provided does not show that the criteria for coverage of SNF care have been met. The Plan says that the services needed can be provided at a lower level of care.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for a UTI. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was dependent with functional mobility and had difficulty following commands. The enrollee required assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 12, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on February
12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (78452)
provided on March 3, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

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 $350 per
day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an
outpatient hospital or ambulatory surgical center.

You have been asked to pay a $325 copayment for the diagnostic test/procedure provided at an outpatient
hospital. This amount is less than the applicable copayment for this service. 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 the myocardial perfusion imaging (78452) provided on March 3, 2021.
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 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 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. 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. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 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 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. 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. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation and management service (99443) provided on March 8, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $15 for each covered visit or consultation in an outpatient location with your PCP or other primary care physician.

You have been asked to pay a $15 copayment for the telehealth visit provided. The copayment amount was adjusted previously by the Plan to reflect this liability. 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 the telephone evaluation and management service (99443) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the retreatment of previous root canal therapy (D3348). We decided that the Plan does not have to pay for the drugs or medicaments (D9630).

You asked the Plan to pay for the retreatment of previous root canal therapy (D3348) and drugs or medicaments (D9630). You say that nobody informed you that the doctor was not in-network. You say that the doctor had a duty to inform you that he was not in-network and you should be refunded the out-of-pocket sum of $580. The Plan says that the claim reprocessed to apply the in-network rate.

We decided that the Plan has to reduce the cost for the retreatment of previous root canal therapy (D3348).

The Evidence of Coverage clearly states you pay $373 for the retreatment of previous root canal therapy (D3348). Therefore, we decided that the Plan has to reduce the cost for the retreatment of previous root canal therapy (D3348) from $425 to $373.

We also decided that the Plan does not have to pay for the drugs or medicaments (D9630).

The Plan contract includes a list of covered supplemental dental benefits. The drugs or medicaments (D9630). is not on this list and is not a covered supplemental benefit. Therefore, we decided that the Plan does not have to pay for the drugs or medicaments (D9630).

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 10, 2020 by a non-network provider.
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 were rendered by a non-network provider without 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 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 provided on December 10,
2020 by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on December 29, 2020.

You asked the Plan to pay for the refraction. You say that it doesn't make sense that the Plan pays for glasses
but not the information needed to get the right prescription. You say that this should be part of any new glasses
that are ordered. The Plan denied your request. The Plan says eye refractions performed by a specialist are not
covered.

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 the refraction when provided by an optometrist.

We looked at the file and the Plan's rules. A refraction is not covered when provided by an ophthalmologist.
Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met.
Therefore, we decided that the Plan does not have to pay for the refraction provided on December 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mediastinoscopy, or Bronchoscopy provided on December 30, 2020.

You asked the Plan to pay for Mediastinoscopy; with lymph node biopsy(ies) (39402) and Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage (31624). You say that the Plan should pay the claim. The Plan denied your request. The Plan says the documentation submitted did not include documentation of mediastinoscopy or bronchoscopy.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 39402 and 31624 are not supported in the medical record. Specifically, there is no documentation of the procedures in the case file. Based on this information, we decided that Medicare rules for coverage of Mediastinoscopy; with lymph node biopsy(ies) (39402) and Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage (31624) have not been met. Therefore, we decided that the Plan does not have to pay for the Mediastinoscopy, or Bronchoscopy provided on December 30, 2020.