Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the services you received May 17, 2019, to January 30, 2020.You asked the Plan to waivethe copayments. The Plan denied your request. The Plan says you are responsible for the cost share.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 $25 copayment for specialist services. Review of the file shows that you were provided specialist services on five occasions from May 17, 2019, to January 30, 2020. You have been asked to pay a $25 copayment for each of the services. The services fall within the specialist services 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 contractualobligation 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 services you received May 17, 2019, to January 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation visits provided from January 20, 2020 to February 19, 2020.
You asked the Plan to waive the copayments for the cardiac rehabilitation visits. You say that cardiac rehabilitation services are 100% covered under Medicare. 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 $20 copayment per visit for cardiac rehabilitation services. You have been asked to pay a $20 copayment for each of the cardiac rehabilitation visits. The cardiac rehabilitation visits fall within the "Cardiac rehabilitation services" 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 cardiac rehabilitation visits provided from January 20, 2020 to February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is never covered, as it does not serve a primarily medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
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 it is felt that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says IRF criteria are not met in this case.
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 enrollee was admitted to the hospital on July 25, 2020 with a ruptured/leaking abdominal aortic aneurysm for which she underwent surgical repair. As of the most recent therapy note, the enrollee requires contact guard assist for bed rolling and sitting up, and minimal assist for standing, bed/chair transfer and sitting up. 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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve a ataxia comprehensive evaluation test and ataxia friedreich evaluation test.You asked the Plan to pre-approvea ataxia comprehensive evaluation test and ataxia friedreich evaluation test. You say that the requested ataxia comprehensive evaluation test and ataxia friedreich evaluation test are medically necessary.The Plan denied your request. The Plan says that the services are not covered.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 ataxia comprehensive evaluation test and ataxia friedreich evaluation test. Our reviewer says that the requested ataxia comprehensive evaluation test and ataxia friedreich evaluation test are medically necessary. Our physician reviewer found the current standards of care in the evaluation of ataxia involve first looking for reversible causes of ataxia (which has been done here). Subsequently, in the case where the initial workup is negative for obvious and/or reversible causes of ataxia and the if the condition is most consistent with a progressive degenerative condition of the cerebellum and brainstem, then a genetic evaluation for ataxia is indicated. In this case the proposed course of testing would therefore be consistent with the generally accepted standard of practice/care. It can also (potentially) used to guide further management of a patient's condition (were results to return positive for a known syndrome). Consequently, it would meet the Medicare definition of medical necessity and would be considered reasonable and necessary.Please note the Local Coverage Determination and Article the Plan used for their rationale are not in the correct jurisdiction and are not binding 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 a ataxia comprehensive evaluation test and ataxia friedreich evaluation test have been met.Therefore, we decided that the Plan has to pre-approve a ataxia comprehensive evaluation test and ataxia friedreich evaluation test.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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
You asked the Plan to pre-approve Genvisc 850. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been 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 Genvisc 850. Our reviewer says that the medication is not medically necessary. 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. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Genvisc 850 is not approved as step criteria is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
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 medically necessary. The Plan denied your request. The Plan says 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 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 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. 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 admission to an 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 enrollee has an approved home health authorization for PT/OT as part of his discharge planning.
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 based on the records provided, the complexity of the enrollee's nursing, medical, and rehab needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require an intensive inpatient rehabilitation therapy program. There is no documentation that you require an intensive rehab therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health services appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an admission to an inpatient rehabilitation facility (IRF).
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 IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 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. He has been medically stable and does not require any skilled nursing services. The enrollee does require treatment by multiple therapies, including both physical therapy and occupational therapy. He does not require an intensive rehabilitation therapy program in order to receive services. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. He is able to participate with skilled therapy and has already made progress and is able to ambulate, transfer and accomplish activities of daily living with minimum assistance. The enrollee continues to have a need for skilled therapy with ongoing safety concerns however, the documentation doesn't support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that he would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. He is ambulating up to 80 feet with minimal assistance. He is near his prior level of function and could receive services 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee requires ongoing therapy.The Plan denied your request. The Plan says that the care is not complex enough and does not show it would cause excessive physical hardship for the patient to receive needed care on an outpatient basis or skilled nursing facility.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 requestto pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. It is not clear the member would be able to fully benefit and/or participate in an IRF level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We lookedat 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional component of the blood typing services provided on October 10, 2019 billed with CPT codes 86900-26 and 86901-26.
You asked the Plan to pay for the interpretation of blood typing testing. You say that this should be paid. The Plan denied your request. The Plan says these codes are not payable when billed for the professional component only.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the codes 86900 and 86901 are not payable on the Physician Fee Schedule but have a PC/TC indicator of "9" meaning that the concept of professional/technical components does not apply. These services are paid in the Clinical Laboratory Fee Schedule and only have a fee for the global service, and no breakdown for PC/TC of the service. This means that payment cannot be made for these codes when billed with the modifier -26. Based on this information, we decided that Medicare rules for coverage of the interpretation of blood typing testing have not been met. Therefore, we decided that the Plan does not have to pay for the professional component of the blood typing services provided on October 10, 2019 billed with CPT codes 86900-26 and 86901-26.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay 50% for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup. We decided that the Plan does not have to pay more than 50% for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup.
You asked the Plan to pay for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup. You say that your EOC shows that you have a $500 comprehensive dental allowance, and it does not show that certain work is not covered. You also say that prior to receiving the services, you contacted the Plan and were told that the $500 would cover the work you had done. The Plan says that the services are not covered. The Plan also says that the call history was reviewed, and shows that you contacted the Plan on January 7, 2020 after the services were rendered.
We decided that the Plan has to pay 50% for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup.
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 does not say in clear and accurate terms that covered services are limited to only those that are listed. We looked at your contract with the Plan. The contract clearly states that resin composites are a covered benefit and you are responsible for a 50% coinsurance. We did not see where the contract says that covered services are limited to only those that are listed in the EOC. The Plan contract does not clearly say that first intraoral periapical x-ray, crown, and core buildup are not covered benefits. This means that the Plan did not follow Medicare rules for providing a clear and accurate description of the benefits offered under the Plan. Therefore, we decided that the Plan has to pay 50% for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup.
We also decided that the Plan does not have to pay more than 50% for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup.
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 Plan is only obligated to pay for 50% of the covered services. Therefore, we decided that the Plan does not have to pay more than 50% for the first intraoral periapical x-ray, crown, resin-based composite, and core buildup.
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 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
enrollee does not meet criteria for IRF admission. 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 evaluation of a seizure. He has
persistent weakness. All chronic medical problems are stable. He has received physical therapy services while
in the hospital but has not required occupational therapy or speech therapy services. There are no complex
nursing, medical 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. 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 pre-approve the use of HMO benefits for an upcoming appointment.
You asked the Plan to pre-approve the HMO benefits. You say that you would like reconsideration because the member needs to continue treatment with this provider. The Plan denied your request. The Plan says the member can see a provider within the primary network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that Care ordered by a physician who you are seeing under your POS benefits, even when provided at a network facility will all be covered under your POS benefits and higher coinsurance or copayments will apply. 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 use of HMO benefits for an upcoming appointment.