Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs can continue to be met in the skilled nursing facility setting.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the PET scan and the medical supply provided on January 11, 2021.
You asked the Plan to reduce the cost share for the PET scan and the medical supply. You say that your Evidence of Coverage states there is a $110 copayment for the PET scan. 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 $110 copayment for Medicare-covered in-network radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic) and 20% coinsurance each in-network Medicare-covered medical supply. You have been asked to pay a $110 copayment for the PET scan and $605.90 which is 20% of the allowed amount for the medical supply. The allowed amount is $3,029.49. ($3,029.49 20%= $605.90). ($110 + $605.90 = $715.90). The PET scan and the medical supply 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 reduce the cost share for the PET scan and a medical supply provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on September 14, 2020, by an in-network provider.

You asked the Plan to waive the copayment for urgent care services. You say that you were informed that there would be no copayment on any doctor's visits during the pandemic. The Plan denied your request. The Plan says you are responsible for the cost share of $40 as outlined in your plan benefits. The Plan states while the plan was waiving the cost share for some services due to Covid, urgently needed copayments still apply.

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 show that you received urgent care services on September 14, 2020, by an in-network. The Plan asked you to pay a $40 copayment for the urgent care services. However, your 2020 EOC states that enrollees must pay a $30 copayment for each visit in a contracted Urgent Care Center or walk-in clinic. Therefore, you are responsible for a $30 copayment for the services, and the Plan has to reimburse the additional $10 if you have already paid the $40 copayment. 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 urgent care services provided on September 14, 2020, by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair (E1038).

You asked the Plan to pre-approve the transport chair. You say that you would like reconsideration because the manual wheelchair is too heavy and the member needs a transport chair at the advice of their doctor. The Plan denied your request. The Plan says a lightweight wheelchair is more appropriate to meet the member's needs.

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 transport chair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that a transport chair is medically reasonable and necessary in place of a lightweight manual wheelchair. The provided physical therapy assessment documents the benefits of the lightweight manual wheelchair as a better option 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 transport chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a transport chair (E1038).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the AIM UTI Molecular Pathogen Identification Test Panel provided on January 13, 2021.
You asked the Plan to pay for the molecular testing. You say that you would like reconsideration because you continue to do your part in providing timely testing and results to the Covid-19 pandemic. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the molecular testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include medical records to verify why this testing was ordered. Therefore, we decided that the Plan does not have to pay for the AIM UTI Molecular Pathogen Identification Test Panel provided on January 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for complete ultrasound of arm or leg (CPT code 76881) provided on October 20, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that this was not the correct procedure to treat your knee. 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 show that you received an ultrasound on October 20, 2020. The Medicare-allowed amount for the ultrasound is less than the set $160 copayment; therefore, you have been asked to pay the lesser amount of $105.68 for the ultrasound. 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 complete ultrasound of arm or leg (CPT code 76881) provided on October 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Request for Anticipated Payment (RAP) filed for date of service May 22, 2020.

You asked the Plan to pay for the RAP as billed. You say that you feel that this RAP should be paid. The Plan denied your request. The Plan says payment was made for this RAP on June 30, 2020, but no final claim for this episode had been filed by November 27, 2020. At that time, the Plan correctly recouped the payment made on the RAP.

The Plan must follow Medicare rules. Medicare rules say that payments made for RAPs may be recouped if a final claim for the episode of care is not submitted within a certain timeframe. 

In this case, a final claim had not been submitted by 60 days beyond June 30, 2020. Recoupment is found to be correct in this circumstance. Therefore, we decided that the Plan does not have to pay for the Request for Anticipated Payment (RAP) filed for date of service May 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session, 60 minutes (90837) provided on October 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no adequate time frame to obtain authorization for the service. The enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 individual psychotherapy session, 60 minutes (90837) provided on October 12, 2020 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 ultrasound of the breast provided on May 6, 2019.

You asked the Plan to waive the copayment for an ultrasound of the breast. You say that you feel that this is a preventative service and should not have a copayment. 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 $150 copayment for diagnostic radiology services. 

You received an ultrasound of the breast on May 6, 2019. An ultrasound of the breast is not included in breast cancer screenings. Therefore, you are responsible to pay the $150 copayment. 

You have been asked to pay a $150 copayment for an ultrasound of the breast. An ultrasound of the breast 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 ultrasound of the breast provided on May 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the paring or cutting of a benign hyperkeratotic lesion (11056) provided on February 11, 2021.

You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the service provided.

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 $750 deductible each calendar year. Until you have paid the deductible amount, you must pay the full cost of your covered services. 

You have been asked to pay $77.99 for the podiatry service provided. This is the Plan allowed amount for this service. The Plan contract says that you must pay a $750 deductible each calendar year. Until you have paid the deductible amount, you must pay the full cost of your covered services. This amount will be applied to the yearly deductible. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost share is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the cost share for the paring or cutting of a benign hyperkeratotic lesion (11056) provided on February 11, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that your care needs can continue to be met in the skilled nursing facility setting.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), and palliative (emergency) treatment of dental pain (D9110) provided on October 29, 2020.

You asked the Plan to pay for the intraoral periapical x-rays, bitewing x-rays, and emergency treatment of dental pain. You say that you would like these services to be covered. The Plan denied your request. The Plan says your annual maximum benefit has been exhausted.

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 offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on November 6, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), and palliative (emergency) treatment of dental pain (D9110) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous Iron infusions.

You asked the Plan to pre-approve the intravenous Iron infusions. You say that you would like reconsideration because these infusions are medically necessary. The Plan denied your request. The Plan says the member does not have a covered indication for the requested service.

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 intravenous Iron infusions. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical notes do not mention symptomatic anemia, intolerance to oral iron, or Malabsorption of oral iron. At this time there is no indication for oral iron. 

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 intravenous Iron infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous Iron infusions.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from September 18, 2020, through
October 4, 2020.

You asked the Plan to pay for the SNF services. he Plan denied your request. The Plan says SNF services
provided from September 18, 2020, through October 4, 2020, are not medically necessary.

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 pay for the SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications. The enrollee had stable vital signs. She used oxygen via
nasal cannula. Regarding rehabilitation services, the enrollee required total assist with functional mobility and
extensive assist with activities of daily living. There are no identifiable skilled nursing service needs. There are
no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services
on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service
criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for SNF services provided from September 18, 2020, through October 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The medical records provided do not support that the member has tried and failed the required drugs. Our physician reviewer found the medical records provided do not indicate that the Plan's required drugs would likely be less effective or have adverse effects for the member. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that this would be the best option for you. The Plan denied your request. The Plan says that the services you need can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.