Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy services rendered to you from January 3, 2019 to September 30, 2019.
You asked the Plan to waive the copayments for these services. You say that the copayments are a financial hardship. The Plan denied your request. The Plan says the copayments were 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 $30 copayment for outpatient rehabilitation services.
Review of the file shows that you had 27 sessions of physical therapy from January 3, 2019 to September 30, 2019. You have been asked to pay a $30 copayment per visit for these services, for a total of $810. These services fall within the outpatient 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 the physical therapy services rendered to you from January 3, 2019 to September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee would be able to reach prior level of function. The Plan denied your request. The Plan says the enrollee does not have medically complex conditions requiring physician management, intensive therapy, or an intensive team for care.
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 physician reviewer found that the enrollee was most recently admitted for dizziness and nausea. History is notable for coronary artery disease. Imaging revealed possible posterior circulation ischemia. Physical therapy was involved to treat the member's vertigo and dizziness. The enrollee is medically, and neurologically stable. The complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is at minimal to standby assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not indicate a need for the noninvasive ventilator.
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 home ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not cover a home ventilator when used as BiPAP. There is no evidence of BiPAP failure, and the member was noted to improve in the hospital on BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE mode that is being requested here. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a clasp to an existing partial denture (D5660) provided on October 16, 2019.
You asked the Plan to pay for the dental service. You say that your doctor advised that you need a new partial denture. You also say that you cannot afford to pay the bill for the service. The Plan denied your request. The Plan says the denture adjustment is not a covered service.
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 denture adjustment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the addition of a clasp to an existing partial denture (D5660) provided on October 16, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency room services (99285 and 70450) provided on July 8, 2019.
You asked the Plan to pay for the emergency room services. You say that you would like reconsideration as the injury occurred on private property and the vehicle involved has no insurance coverage. The Plan denied your request. The Plan says that there is no letter from the car insurance company to confirm there was no coverage.
The Plan must follow Medicare rules. Medicare rules say that plans must identify payers that are primary to Medicare, identify the amounts payable by the primary payer, and coordinate benefits to Medicare enrollees with the benefits of the primary payer. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency room services have been met. Specifically, the Plan has not identified the primary payer, amount payable or coordinated benefits. Therefore, we decided that the Plan has to pay for emergency room services (99285 and 70450) provided on July 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient SNF rehabilitation services provided from August 29, 2019 to September 4, 2019.
You asked the Plan to pay for the inpatient SNF services. You say that a SNF was the only option mentioned as being a safe medical plan for the enrollee. You also say that the enrollee's family was in agreement that the enrollee required a SNF with 24-7 care and a focused physical therapy and occupational therapy plan before returning to her independent living situation. The Plan denied your request. The Plan says the services were 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 above 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 inpatient SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 inpatient SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient SNF rehabilitation services provided from August 29, 2019 to September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7140) provided on September 20,
2019.
You asked the Plan to pay for 1 surgical extraction. The Plan denied your request. The Plan says the maximum
allowance of $150 has been exceeded. The Plan says that services are only covered when received by a
participating provider. The Plan also says that the provider in this case is not a participating provider.
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 maximum allowance for
comprehensive dental services has been exceeded. Additionally, the provider in this case is not a network
provider. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7140) provided
on September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately managed in his current condition at a skilled level of care. The Plan denied your request. The Plan says the enrollee requires interventions that are normally performed in acute hospitals.
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 physician reviewer found that the enrollee is currently undergoing treatment as an outpatient for end-stage renal disease. An LTACH admission has been requested to provide the patient with chronic wound care. The enrollee is not shown to be in need of long-term acute care. Therefore, admission to a LTACH is not currently medically necessary or reasonable. 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 for the enrollee.
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 this is medically necessary and the enrollee would be at a greater risk at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee can be treated at the current acute care hospital.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is currently receiving acute hospital care. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection (27096).
You asked the Plan to pre-approve a SI joint injection (27096). You say that the requested SI joint injection is medically necessary. The Plan denied your request. The Plan says the requested SI joint injection 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 pre-approve a SI joint injection (27096). Our reviewer says that the requested SI joint injection is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. He currently takes Diclofenac gel and Gabapentin. His MRI shows both degenerative disc disease as well as facet arthropathy. He had an epidural steroid injection at L5-S1 on 11/14/19 and had between 60 to 100% pain relief but is still having pain when standing. The request is for a SI joint injection. There are no SI joint loading tests or other SI joint physical exam findings documented. There are no physical exam findings documented that support the diagnosis of SI joint dysfunction. There is no recent imaging of the SI joint. The requested procedure is not medically reasonable or necessary. 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 SI joint injection (27096) have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered to the enrollee on August 29, 2019.
You asked the Plan to waive the copayment for these services. You say that the enrollee wasn't seen by the doctor. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for per specialist visit.
Review of the file shows that the enrollee received services in a specialist's office on August 29, 2019. The enrollee has been asked to pay a $40 copayment these services. These services fall within the specialist visit 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 the physician services rendered to the enrollee on August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the abdomen rendered to you on October 8, 2019.
You asked the Plan to waive the copayment for these services. You say that the enrollee has been pre-approved
for the last three years. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for diagnostic radiology other than computed tomography (CT) scans.
Review of the file shows that you received an MRI of the abdomen on October 8, 2019. You have been asked
to pay a $200 copayment for these services. These services fall within the diagnostic radiology other than
computed tomography (CT) scans benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. The Plan is not denying coverage of these services. 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 magnetic resonance imaging (MRI) of the abdomen
rendered to you on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 20, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was a wellness exam. You say that you should not have any responsibility. 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 $15 copayment for each in-network primary care doctor office visit for Medicare-covered services. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for hyperlipidemia. 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 November 20, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the Part B injections provided on December 21,
2018.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you have had seven
treatments and the first four have been paid in full. You say these should be paid in full as well. The Plan
denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There was no Explanation of Benefit or claim form submitted with the code at
issue to verify the billed services. Therefore, the plan has not shown that the coinsurance amount you are being
asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive
the coinsurance for the Part B injections provided on December 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sling operation for stress incontinence (57288).
You asked the Plan to pre-approve a sling operation for stress incontinence. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee has failed non-surgical measures.
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 a sling operation for stress incontinence. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that you have tried and failed non-surgical management with behavior modification, pelvic floor exercises or pharmacotherapy. Physicians should perform additional evaluations in patients being considered for surgical intervention who have urgency-predominant mixed urinary incontinence or when there is inability to make definitive diagnosis based on symptoms and initial evaluation, as is the case with 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 a sling operation for stress incontinence have not been met. Therefore, we decided that the Plan does not have to pre-approve a sling operation for stress incontinence (57288).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Etelcalcetide for the enrollee.
You asked the Plan to pre-approve Etelcalcetide. The Plan denied your request. The Plan says that there is no indication that the enrollee has chronic kidney disease versus end-stage renal disease.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Etelcalcetide. Our physician reviewer found that the enrollee has end-stage renal disease and refractory secondary hyperparathyroidism. This enrollee can be classified as tertiary hyperparathyroidism. They have a PTH of over 2000, and refuse a parathyroidectomy. The enrollee has failed conventional therapy, including Sensipar. The enrollee does meet criteria for the use of Parsabiv (Etelcalcetide) based on lab results and having failed Sensipar therapy. This would be considered standard of care progression of therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Etelcalcetide have been met. Therefore, we decided that the Plan has to pre-approve Etelcalcetide for the enrollee.