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

We decided that the Plan does not have to pay for the Duplex scan of extremity veins (93970) provided by an out of network (OON) provider.

You asked the Plan to pay for the Duplex scan. You say that the services were necessary. The Plan denied your request. The Plan says the criteria for OON coverage for the service were not met.

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 Duplex scan of extremity veins (93970) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided by a participating provider.

You asked the Plan to waive the copayment for an ECG. You say that this should have been part of your annual exam. 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 $40 copayment for outpatient diagnostic tests/non-radiological diagnostic services/in-network.

You have been asked to pay $18.75 which is less than your copayment amount of $40 for an ECG. When additional services are provided during an annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied. An ECG falls within the outpatient diagnostic tests/non-radiological diagnostic services/in-network 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 ECG provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the 3-D radiographic procedure or the ultrasounds provided on August 24, 2020 and September 8, 2020.
You asked the Plan to waive the copayments for the radiographic procedure and the ultrasounds. You say that you are appealing these bills. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). You have been asked to pay a total of $176.03 for the radiographic procedure and the ultrasounds. The radiographic procedure and the ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 copayments for the 3-D radiographic procedure or the ultrasounds provided on August 24, 2020 and September 8, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, 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 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-approve continued inpatient mental health care beyond March 6, 2021.
You asked the Plan to pre-approve continued inpatient mental health care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient mental health care. Our reviewer says that the criteria for continued inpatient care have not been met. Our physician reviewer found based on the records provided, it is not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care beyond March 6, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea injection 2 mg/0.5 ml (J0178).
You asked the Plan to pre-approve the Eylea injection. You say that unfortunately your providers do not use
Avastin. Dr. Contractor feels it is medically necessary for this enrollee to have Eylea injection due to their
diagnosis of BRVO with macular edema. The Plan denied your request. The Plan says there was no indication
that the plan-preferred agent would not be clinically appropriate for the member.
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 the Eylea injection. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Plan requires a trial of drug Avastin before they will approve the requested drug.
In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided
indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for
the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Eylea injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve Eylea injection 2 mg/0.5 ml (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on September 16, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you would like this copayment waived. The Plan denied your request. The Plan says these services were not listed as telehealth services; therefore, 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 $35 copayment for physician/practitioner services/specialist. You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/specialist 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 specialist office visit provided by a participating provider on September 16, 2020.
We note your complaint about wanting this copayment waived because of Covid-19. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this service is necessary. The Plan denied your request. The Plan says that prior authorization criteria has not been met.
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. In this case, we requested additional medical records supporting the request for the CGM and to see if the criteria has been met. A response to this request has not been received. Therefore, we decided that the Plan has to pre-approve the Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 26, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections.
You asked the Plan to pre-approve the SI joint injections. You say that you believe that these should be covered to help with your pain. The Plan denied your request. The Plan says there is not sufficient evidence in the record that your pain comes from the SI joint.
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 SI joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 67-year-old woman has chronic low back pain. She takes oxycodone, Tizanidine and meloxicam. There is no documentation of physical exam findings that support the diagnosis of SI joint dysfunction. Without positive physical exam findings, the injections are considered not medically reasonable or necessary at this point. 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 SI joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from July 4, 2019 to July 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the payment of DRG 698 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 698 is defined as "OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC." In this case, you billed the services provided July 4, 2019 and July 5, 2019 with DRG 698. 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 pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found a diagnosis of sepsis was in the differential and he was admitted with DRG 698. The Sequential Organ Failure Assessment (SOFA) score was 2-3 primarily based on altered mental status and acute kidney injury (1.9). Blood pressure was 99/53. Mental status improved with fluids and antibiotics. Based on the provided documentation, the DRG 698 was appropriate as the patient at a SOFA of 2-3 and possibly had sepsis. 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 services have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from July 4, 2019 to July 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extended visits to be provided by an out of network provider.
You asked the Plan to pre-approve extended visits. You say that you have out-of-network benefits you can use but the extended sessions were denied. The Plan denied your request. The Plan says the records do not show the necessity for frequent extended visits.
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 provider at issue in this case is not a network provider with the Plan. 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 extended visits. Our reviewer says that you have out-of-network benefits and may continue to receive the out-of-network services, but the documentation does not support that extended office visits are medically reasonable and necessary 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 extended visits have not been met. We found no exception that would require the Plan to pre-approve extended visits. Therefore, we decided that the Plan does not have to pre-approve extended visits to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, such as: a skilled nursing facility, or home with home health services.
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 that you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray (71045) provided November 9, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you had recently moved and disagree with the copayment. 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 $45 copayment for Basic Radiological Services provided at a specialist's office or freestanding radiological facility. You have been asked to pay $30.32 as your copayment for the x-ray. This service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 the chest x-ray (71045) provided November 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs.

You asked the Plan to waive the coinsurance for the Part B drugs. You say that you were told you would pay no more than a $50 copayment for your infusions. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% coinsurance for in-network Part B covered drugs.

You have been asked to pay a total of $2,280.24 for the Part B drugs. The Part B drugs falls within the "Medicare Part B prescription drugs" benefit category. See chart provided.

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 Part B drugs.