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

We decided that the Plan does not have to pre-approve eyelid surgery to be provided by an out of network
(OON) provider and facility.
You asked the Plan to pre-approve eyelid surgery to be provided by an OON provider and facility. You say that
the enrollee wants to continue receiving care from this provider. The Plan denied your request. The Plan says
there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been
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 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
eyelid surgery to be provided by an out of network (OON) provider and facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 January 29, 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are able to walk six feet with a rolling walker. You required moderate to maximum assistance with transfers. You required mostly moderate assistance for activities of daily living. You have a Foley catheter and are on 2 liters of nasal cannula oxygen. The documentation does not support that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical therapy and occupational therapy, the documentation does not support that you require treatment in an intensive rehabilitation therapy program. Your therapy 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya injections (Tildrakizumab code J3245).
You asked the Plan to pre-approve the Ilumya (Tildrakizumab). You say that the enrollee has only ever used topical therapy to treat her psoriasis. You also say that photo therapy would not be an option for the enrollee. The Plan denied your request. The Plan says the guidelines for Ilumya treatment require that the enrollee has a trial of at least two of the preferred drugs. The Plan also says that there was no indication in the documentation submitted that the enrollee has tried any of the preferred medications.
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 Ilumya (Tildrakizumab). Our reviewer says that Ilumya injections for this enrollee does not meet coverage criteria. Our physician reviewer found because the enrollee has a severe form of psoriasis and has tried and failed several topical medications, the use of a biologic is warranted at this time. The drug Skyrizi, offered by the Plan, has the same mechanism of action as requested Ilumya, but more convenient schedule and therefore may be tried first.
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 Ilumya (Tildrakizumab) have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya injections (Tildrakizumab code J3245).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of an inpatient psychiatric admission for the enrollee.
You asked the Plan to pre-approve the additional days. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 the additional days. Our reviewer says that the requested additional days are not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for this treatment in an acute inpatient mental health treatment beyond the date in question of June 2, 2020 forward, and could not have been treated in a lesser restrictive setting, as he was not showing any suicidal or homicidal ideation, chronic auditory or visual hallucinations, no delusions, and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 additional days have not been met. Therefore, we decided that the Plan does not have to pre-approve additional days of an inpatient psychiatric admission for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive he copayment for a Positron Emission Tomography (PET) scan (78815) with an injection (A9552) provided January 10, 2020.
You asked the Plan to waive he copayment for the PET scan and injection. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $115 copayment for Diagnostic Radiology and a $50 copayment for injections. You have been asked to pay a $165 copayment for the PET scan and injection. 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 he copayment for a Positron Emission Tomography (PET) scan (78815) with an injection (A9552) provided January 10, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a duplex scan of lower extremity arteries (93925) and retroperitoneal ultrasound (76775).
You asked the Plan to pre-approve a duplex scan of lower extremity arteries and retroperitoneal ultrasound. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
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 a duplex scan of lower extremity arteries and retroperitoneal ultrasound. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found while the ankle-brachial indices are lower limits of normal the enrollee has significant risks for atherosclerotic peripheral vascular disease and due to lower extremity swelling has a difficult physical exam. Certainly there is abundant indication for the peripheral venous ultrasound requested and due to the comorbidity factors it is prudent to evaluate the arterial side of the peripheral vascular system in light of the severe symptomatology. Thus, despite the normal ankle brachial indices there is significant clinical indication for lower extremity peripheral arterial ultrasound. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a duplex scan of lower extremity arteries and retroperitoneal ultrasound have been met. Therefore, we decided that the Plan has to pre-approve a duplex scan of lower extremity arteries (93925) and retroperitoneal ultrasound (76775).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on November 14, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that you were informed the provider isn't a
participating facility. You say that you want to know if the copayment is correct. The Plan denied your request.
The Plan says the copayment 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 $100
copayment for basic radiological services at an in-network outpatient hospital.
You have been asked to pay $72, which is less than the standard $100 copayment for the x-ray. The x-ray 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 x-ray provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the annual wellness visit provided on
January 23, 2020.
You asked the Plan to waive the coinsurance for the annual wellness visit. You say that you don't understand
why you are being charged. You say that this should be a Medicare covered service. The Plan denied your
request. The Plan says the coinsurance 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 30% of
the total allowed amount for a Medicare-covered preventive annual wellness exam from an out-of-network
provider.
You have been asked to pay $37.66, which is 30% of the allowed amount for the annual wellness visit. The
allowed amount is $125.54 (30% x $125.54 = $37.66). The annual wellness visit falls within the "Annual
wellness visit" benefit category. The records show that the provider is out-of-network. 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 annual wellness visit provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 9, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says there is no evidence of a relationship with the ordering
physician as required per CMS guidelines.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain valid proof of delivery for the supplies provided in
this case. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on
October 9, 2019.
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 this is medically necessary. The Plan denied your
request. The Plan says the requested services do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate
that this therapy must be in an IRF with an intensive level program.
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 pay for post-stabilization inpatient care provided December 7, 2019 to December 10, 2019.
You asked the Plan to pay for the post-stabilization inpatient care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization inpatient care. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. The record shows the enrollee was stable for transfer for the post-stabilization 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 the post-stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided December 7, 2019 to December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on
December 19, 2019.
You asked the Plan to pay for the topical application of fluoride varnish. You say that the Plan should be
responsible for this bill because a Plan representative referred you to this provider. The Plan denied your
request. The Plan says this service is not a covered benefit under your dental plan.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
topical application of fluoride varnish provided on December 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (Hyaluronan or derivative code J7318).
You asked the Plan to pre-approve the Durolane. You say that Medicare guidelines allow Durolane every 6 months. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage. The Plan also says that documentation supporting the medical necessity for a step therapy exception was not received.
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 Durolane. Our reviewer says that Durolane does not meet coverage criteria. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed first. Our reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (Hyaluronan or derivative code J7318).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 8,
2020 through January 28, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on January 8, 2020 and discharged on January 10, 2020. You
were asked to pay a $250 copayment per day from January 8, 2020 through January 9, 2020, days 1-2 of your
inpatient hospital care. You were discharged on January 10, 2020 and there was no copayment charge for the
day of discharge.
Furthermore, you were admitted on January 21, 2020 and discharged on January 28, 2020. You were asked to
pay a $250 copayment per day from January 21, 2020 through January 27, 2020, days 1-7 of your inpatient
hospital care. You were discharged on January 28, 2020 and there was no copayment charge for the day of
discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 inpatient hospital care from January 8, 2020 through January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 17,
2019.
You asked the Plan to waive the copayment for the office visit. You say that this visit should be covered in full
because it was your annual wellness visit. The Plan denied your request. The Plan says you have been charged
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 $10
copayment for each primary care doctor office visit for Medicare-covered services.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medial record shows you were also
seen for a follow-up for multiple problems, in addition to the annual wellness visit.
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 office visit provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral prescription drug rendered from October 24, 2019 to
October 25, 2019.
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 are not covered.
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every
HCPCS code and identifies whether the service described by the HCPCS code is paid under the OPPS.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code J8999. This code
has an OPPS status indicator of B and is not payable. Based on this information, we decided that Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for the oral prescription drug rendered from October 24, 2019 to October 25, 2019.