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

We decided that the Plan does not have to pay for the WATS 3D testing provided on December 3, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the American Society of Gastrointestinal Endoscopy (ASGE) makes a conditional recommendation
for use of WATS 3D testing with low quality of evidence. Several other societies, including the American
College of Gastroenterology and the Gastrointestinal Pathology Society do not recommend this testing.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the WATS 3D testing provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sacroiliac joint injection provided on February 28, 2020.
You asked the Plan to pay for the provided services. You say that the enrollee was seen for severe left-sided
lower back pain. The Plan denied your request. The Plan says there is no evidence of a reasonable course of
conservative treatment prior to injection.
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under
certain medical indications.
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 provided services. Our physician
reviewer found that the enrollee presented with low back pain x 1 week, after a fall. He received a sacroiliac
joint injection. In this case, the enrollee had an acute injury, and there was no evidence of a reasonable course
of conservative treatment prior to the injection. Based on the provided rules and records, the provided injection
was not medically reasonable or necessary to treat the enrollee's condition.
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 provided services have not been met. Therefore, we decided that the Plan
does not have to pay for the sacroiliac joint injection provided on February 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve diagnostic tests. You say that due to COVID-19, having this service done at
home minimizes the chances of the enrollee getting sick. The Plan denied your request. The Plan says the
denial of authorization for these services is correct, because this provider is out-of-network with the Plan and
these same diagnostic services can be performed by an in-network provider.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay December 22, 2019 to December 23, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that only the $90 emergency room copayment should be applied. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $675 copayment for Inpatient Care. The enrollee has been asked to pay a $675 copayment for the inpatient hospital stay. the inpatient hospital stay falls within the Inpatient Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay December 22, 2019 to December 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs can be managed at a
lower level of care. You say that the clinical summary and documentation support the request for LTACH care.
The Plan denied your request. The Plan says the records received do not indicate that LTACH care is medically
necessary. The Plan says that the enrollee can safely receive the needed care in another setting.
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 is currently undergoing treatment at an acute care hospital (ACH)
recurrent aspiration in the setting of dementia and bedbound status. The enrollee is not intubated/ventilated.
There is no evidence that the enrollee requires services that are not currently available. There is no advantage in
transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no
acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any
ongoing long term care needs.
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit with a dermatologist (99203). You asked the Plan to pre-approve an office visit with a dermatologist. You say that the service is necessary. The Plan denied your request. The Plan says that a referral to an otolaryngologist is needed for your health issue as opposed to a dermatologist. 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 an office visit with a dermatologist. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found a dermatologist is the appropriate specialist to evaluate your skin lesion. It is not documented in the case file that the dermatology office is unable to evaluate and manage your condition. A dermatology consult is medically reasonable and necessary for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit with a dermatologist have been met. Therefore, we decided that the Plan has to pre-approve an office visit with a dermatologist (99203).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not met step therapy requirements.
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 Euflexxa. Our reviewer says that the
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of
drugs Orthovisc and Monovisc first before they will approve the requested drug, Euflexxa. The provided
medical records do not indicate that the enrollee has tried these drugs or that they would likely be less effective
or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa (J7323).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 22, 2019 to December 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found The review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided November 22, 2019 to December 6, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and laboratory tests provided on January 9, 2020.
You asked the Plan to waive the copayments for a specialist visit and laboratory tests. You say that you 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 $35 copayment for laboratory services provided in an outpatient hospital facility. Your contract with the Plan also clearly says that you must pay a $50 copayment for specialist visits. You received a specialist visit on January 9, 2019. Therefore, you are responsible to pay the $50 copayment. You received laboratory tests on January 9, 2019. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $85. You have been asked to pay the total amount of $85 for a specialist visit and laboratory tests. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. Laboratory tests 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 a specialist visit and laboratory tests provided on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a therapeutic injection provided on November 5, 2019.
You asked the Plan to waive the copayment for a therapeutic injection. You say that you 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 $200 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $175.30, which is less than the $200 copayment for a therapeutic injection. A therapeutic injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 therapeutic injection provided on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance services for the enrollee.
You asked the Plan to pre-approve ambulance services. You say that the enrollee needs this to get to hemodialysis treatment. The Plan denied your request. The Plan says that this is not medically needed.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance services. Our reviewer says that ambulance services are not medically reasonable and necessary for the enrollee in this case. There is no documentation to support that other means of transport are contraindicated for this patient. There is no documentation to support that the patient needs the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for ambulance services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from November 7, 2019 to
November 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home
health services under a plan of treatment.
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB
code. 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 home health services rendered from
November 7, 2019 to November 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy surgery.
You asked the Plan to pre-approve knee arthroscopy. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these surgical services are not medically 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 knee arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided by the surgeon to support meniscal repair over the documented treatment plan of meniscectomy. Additionally, there is no discussion of the medical necessity of synovectomy or evidence of chronic inflammation or extensive synovitis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy surgery.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from December 24, 2019 to December 25, 2019.
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your request. The Plan says that the enrollee did not require inpatient care. The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 inpatient care. Our reviewer says that the inpatient care at issue meets criteria for coverage. Our physician reviewer found the enrollee presented to the emergency department reporting increased dyspnea on exertion, leg edema with pain, and reported diuretic medication non-compliance. The enrollee was treated with intravenous diuretic and antibiotics for the treatment of leg wounds. The enrollee improved, was transitioned to oral medications and discharged on December 25, 2019. The enrollee participates in a PACE plan. As such, documentation only must support that the requested services are services necessary and reasonable to meet the participant's needs and to improve and maintain the participant's overall health status. The documentation does support a noted benefit to the enrollee from this hospital state. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have been met. Therefore, we decided that the Plan has to pay for inpatient care provided from December 24, 2019 to December 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ibandronate Sodium tablets.
You asked the Plan to pre-approve Ibandronate Sodium. You say that Ibandronate Sodium is medically necessary. The Plan denied your request. The Plan says the requested drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ibandronate Sodium tablets.
Benefits for Ibandronate Sodium may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRA provided on December 11, 2019.
You asked the Plan to waive the copayment for an MRA. You say that you should not be responsible for the charges because you had a bad reaction to the dye. 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 $225 copayment for each advanced imaging service. You have been asked to pay a $225 copayment for an MRA. An MRA 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 an MRA provided on December 11, 2019.