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

We decided that the Plan does not have to pre-approve LTACHservices.You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition;the enrollee does not meet all the requirements for an LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted to the current acute care hospital with COVID-19 pneumonia and respiratory distress. He was treated with high flow oxygen, BiPAP, Remdesivir, steroids, and convalescent plasma. Recent notes state that the enrollee was still requiring high flow oxygen and BiPAP at night and required diuresis. He had an episode of hypotension and fever requiring Levophed and Cozaar discontinuation. Blood cultures were drawn but not yet resulted.The enrollee appears to be unstable with low blood pressure and fever which requires additional short-term acute care services. The enrollee does not require services at the LTACH that are not already available at the current setting.There are no services at the LTACH that the enrollee requires that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary. Continued care at the current setting is appropriate until more appropriate long-term care needs are clearer.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-approveLTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe semi-electric hospital bed (E0260) provided on July 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe hospital bed. You say that you didn't know that you had to go through certain protocol. The doctor provided the letter stating this was medically necessary. You needed to get a bed and just went with the local one.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providersrequire prior authorization before services being rendered.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 forthe semi-electric hospital bed (E0260) provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture, cast metal framework with a resin denture base (D5213).You asked the Plan to pre-approvethe dental item. You say that You say that the partial upper denture is medically necessary.The Plan denied your request. The Plan says The Plan says that the abutment teeth for the partial denture are not healthy. The Plan says that the tooth cannot hold a partial denture if it is not stable. The Plan says the requested partial denture does not meet the criteria for coverage.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 dental item when the services are medically necessary and reasonable. 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 dental item. Our reviewer says that the partial denture is not medically necessary. Our physician reviewer found the reason for the denial was that the abutment teeth needed to support the partial are not sound. The reviewer found that the provided documentation included two panorex radiographs of seemingly different people. The reviewer found that without an updated x-ray to show the need for the requested partial denture, medical necessity cannot be found. Therefore, the reviewer found that the requested partial denture cannot be approved at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have not been met.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture, cast metal framework with a resin denture base (D5213).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments forobservation services provided from June 15, 2020, to June 18, 2020.You asked the Plan to waive the copayments forobservation services. You say that you disagree with the outpatient charges because you did not have surgery and were admitted to the hospital.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine what kind of services took place or whether you were admitted inpatient or under observation.Therefore, we decided that the Plan has to waive the copayments forobservation services provided from June 15, 2020, to June 18, 2020.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection of substance into spinal canal (62321) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the injection of substance into spinal canal. You say that the services are medically necessary for the enrollee. The Plan denied your request. The Plan says there are multiple in-network providers available to provide the medical services needed.
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 injection of substance into spinal canal (62321) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug has not met step therapy criteria.
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 Synvisc One. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has pain related to osteoarthritis of bilateral knees, diagnosis confirmed with
imaging studies. The documentation does not support that the enrollee has tried and failed Orthovisc and
Monovisc. The documentation does not support that the required drugs would likely be less effective and/or
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested
drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you can hardly walk from the pain in your feet. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveneuromuscular stimulator, electronic shock unit (CPT Code E0745) provided on June 30, 2020.You asked the Plan to pre-approvethe DME. You say that the DME was necessary.The Plan denied your request. The Plan says the DME was not 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 the DME. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient had tried several steroid injections, medications, and physical therapy with only partial response. A neuromuscular stimulator (TENS) was requested. The NCD states that TENS is not indicated or approved for chronic low back pain, as this patient has. Therefore, the TENS will be considered 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 the DMEhave not been met.Therefore, we decided that the Plan does not have to pre-approveneuromuscular stimulator, electronic shock unit (CPT Code E0745) provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiagnostic eye exam (92014 and 92015) provided on September 1, 2020 provided by a Specialist.You asked the Plan to waive the copayment fordiagnostic eye exam. You say that you were unaware you were seeing a specialist or that there would be a copay.The Plan denied your request. The Plan says the copayment was applied 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 $20 copayment for vision care. You have been asked to pay a $20 copayment for diagnostic eye exam. This service falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fordiagnostic eye exam (92014 and 92015) provided on September 1, 2020 provided by a Specialist.
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 the enrollee's acute needs have been met and stabilized in the acute care setting. You also say that the enrollee is stable to transfer to a LTACH for continuation of care in the long term acute care setting. The Plan denied your request. The Plan says the criteria for admission to a LTACH have not been met.
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 does not require services at the LTACH that are not already available at the current setting. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary at this time. Our physician reviewer also found that transfer may be considered when weaning potential is clearer. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider on September 8, 2020.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this
copayment. 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 $200
copayment for outpatient surgery/in-network/ambulatory surgical center.

You have been asked to pay a $200 copayment for an outpatient surgery. An outpatient surgery falls within the
outpatient surgery/in-network/ambulatory surgical center 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 an outpatient surgery provided by a participating provider on September 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing and physical therapy services from July 
11, 2020, to July 28, 2020. 
 
You asked the Plan to pay for the therapy services. You say that the enrollee was not enrolled in hospice on the 
dates of service. The Plan denied your request. The Plan says during the hospice election, fee-for-service 
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing and 
physical therapy services from July 11, 2020, to July 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the soft tissue of the neck (70490).You asked the Plan to pre-approvethis service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says a CT scan of the neck is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 this service. Our reviewer says that a CT scan of the neck is not medically necessary. Our physician reviewer found that the enrollee had a thyroid ultrasound in September 2020 that was normal. Specifically, it was noted that there were no enlarged lymph nodes at the level of the thyroid. A CT scan has been ordered toevaluate enlarged lymph nodes at the level of the thyroid seen on the ultrasound. It appears that the ultrasound report was misread/misinterpreted.There are no examination or laboratory findings to otherwise justify obtaining a CT scan of the neck. The requested CT scan is not currently 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 this service have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the soft tissue of the neck (70490).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology (88120) provided on March 10, 2020.
You asked the Plan to pay for the cytopathology. You say that you would like reconsideration because there are
no other diagnosis codes available. The Plan denied your request. The Plan says screening services without a
valid medical diagnosis related to the health of the patient are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the cytopathology, was requested solely for screening purposes. Medicare does
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
cytopathology (88120) provided on March 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 28, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 28, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection provided on July 8, 2020.
You asked the Plan to waive the coinsurance for Synvisc injection. You say that you were not expecting a coinsurance for this drug. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $522.65 for the Synvisc injection. The service provided falls within the Medicare Part B prescription drugs 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 coinsurance for the Synvisc injection provided on July 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 28, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you were released from a previous stay too soon and 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 28, 2020.