Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a left total hip arthroplasty.
You asked the Plan to pre-approve this service. You say that an acute inpatient hospital admission is medically necessary for the enrollee. The Plan denied your request. The Plan says an acute inpatient hospital admission is not medically necessary for this surgery.
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 pre-approve the acute inpatient hospital care. Our reviewer says that an acute inpatient hospital admission is not medically necessary. Our physician reviewer found that the enrollee is undergoing a planned left total hip arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27130 is not listed on the CMS Inpatient Only List. There is no specific clinical rationale provided to support the need for an inpatient admission for this procedure. The review has determined that the record does not show that the admitting physician reasonably expects that the patient's necessary hospital 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 the acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a left total hip arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 8, 2020.
You asked the Plan to pay for the office visit. You say that you were being treated for a blood clot. The Plan denied your request. The Plan says the services were received from an out-of-network provider without prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
We looked at the file, and Medicare rules. The records show that you were seen for a new patient visit and follow-up care from an emergency room visit a month prior. The need for follow-up care for the blood clot was known prior to leaving the service area. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5299) purchased on October 20, 2020.
You asked the Plan to pay for the hearing aids. You say that you need these hearing aids, and you were
unaware that you had to check with the Plan to see if you could use your preferred provider. The Plan denied
your request. The Plan says coverage for hearing aids is limited to those provided by the Plan's contracted
vendor. When you use a different provider than the one approved by the Plan, you will be responsible for the
full cost.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are provided by the Plan's contracted vendor.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids (V5299) purchased on October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital admission provided 10/12/2020 to 10/17/2020.
You asked the Plan to pay for the inpatient admission. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says that inpatient level of care was not medically necessary and approved for observational level of care.
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. in this case specific records or information was required to substantiate the plans denial. The medical records were missing from the original file. A request for information was sent to the health plan with a due date of April 13, 2021. As of the date of this letter, the plan has not responded to our request and/or submitted the required information. Therefore, we decided that the Plan has to pay for inpatient hospital admission provided 10/12/2020 to 10/17/2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service (99072) radiologic examination, chest (71046).

You asked the Plan to pay for the urgent care. You say that you were having COVID symptoms and tried to get to your primary care physician's office by no appointments were available. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $35 copay for each covered urgently needed service.

You have been asked to pay $31.15 copayment. The allowed amount of $31.15 is lower than the $35 copayment amount. Therefore, you are responsible for the lesser amount. The urgent care falls within the Urgently needed 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 pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service (99072) radiologic examination, chest (71046).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-stabilization inpatient services provided September 21, 2020 to September 23, 2020.
You asked the Plan to pay for the inpatient services. You say that you are requesting a reconsideration of the denial, review of the medical records and approval of the services provided. The Plan denied your request. The Plan says inpatient care at a non-plan facility was not medically necessary to stabilize the enrollee. The plan approved payment for the emergency stabilization services.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the post-stabilization care services after 12:09 pm on 9/21/20 were not medically necessary or reasonable. The enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility. The physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service the treating. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the post-stabilization inpatient services provided September 21, 2020 to September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on March 23, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient diagnostic tests/advanced imaging services. You have been asked to pay a $150 copayment for an MRI. The correct copayment has been applied to the services that were provided. An MRI falls within the outpatient diagnostic tests/advanced imaging 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 copayment for an MRI provided by a participating provider on March 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the request for this drug for metastatic soft tissue sarcoma is not an FDA-approved or compendia-supported indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Ipilumumab (Yervoy) in combination with pembrolizumab is not FDA approved for use in soft tissue sarcoma. Although there is support in the medical literature in patients who have progressed on prior standard chemotherapies. There is no data to support use in patients that have progressed on prior immunotherapy such as this one. The service is not reasonable or medically 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the intravitreal injection, ophthalmic diagnostic imaging and bevacizumab injection provided on October 15, 2020.
You asked the Plan to waive the cost share for the intravitreal injection, ophthalmic diagnostic imaging and bevacizumab injection. You say that the charge for the injection has increased $26. You say that you want the copayment clarified. The Plan denied your request. The Plan says the cost share 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 each specialist visit for Medicare-covered benefits, 20% of the cost for each Medicare-covered diagnostic radiology and complex imaging service and 20% of the cost per prescription or refill.
You have been asked to pay a total of $55.84 for the intravitreal injection, ophthalmic diagnostic imaging and bevacizumab injection.
Service
Allowed Amount
Standard Cost
Member Liability
Intravitreal Injection
$91.74
$30
$30
Ophthalmic Diagnostic Imaging
$45.20
20%
$9.04
Bevacizumab Injection
$84
20%
$16.80
TOTAL:
$55.84
The intravitreal injection falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The ophthalmic diagnostic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The bevacizumab injection falls within the "Medicare Part B prescription drugs" 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 cost share for the intravitreal injection, ophthalmic diagnostic imaging and bevacizumab injection provided on October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The
Plan denied your request. The Plan says rules for 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 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. Our
physician reviewer found in this case, the patient was admitted to an acute care hospital for pneumonia and
stage IV lung cancer with brain metastasis. The patient does 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.
Finally, there is not a reasonable expectation that this patient 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 pay for the office services (CPT code(s): J3301, 99213, and 20610) provided to the enrollee on September 8, 2020, by a non-participating provider.
You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not considered urgent/emergent in nature. The Plan states they made the final determination to uphold the original denial since prior authorization was not obtained as required under the plan benefits.
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 the office services (CPT code(s): J3301, 99213, and 20610) provided to the enrollee on September 8, 2020, by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography test you had on October 22, 2020.
You asked the Plan to waive the copayment for the echocardiography test. You say that you never had to pay cost sharing for this test with previous insurers. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for radiological diagnostic services (except x-rays) performed in a doctor's office or a free-standing clinic. You have been asked to pay a $100 copayment for the echocardiography test. The echocardiography test falls within the radiological diagnostic services (except x-rays) performed in a doctor's office or a free-standing clinic benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the echocardiography test you had on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that if you do not get the rehabilitation you need you risk
being hospitalized again. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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. Our
physician reviewer found there are no complex nursing or rehabilitation needs. The patient does 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 this patient 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital.

You asked the Plan to waive the copayment for lab work. You say that you get your lab work done at the same building as your doctor. You say that you think you are being overcharged. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were 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 $40 copayment for outpatient diagnostic tests/laboratory test/outpatient hospital facility.

You have been asked to pay $10.77 which is less than your copayment amount of $40 for lab work. Lab work falls within the outpatient diagnostic tests/laboratory test/outpatient hospital facility 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 lab work provided by a participating hospital.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313) and a
seat elevation feature (E2300) for a power wheelchair.
You asked the Plan to pre-approve the expandable controller and seat elevation feature.. You say that the
additional features are medically necessary. The Plan denied your request. The Plan says coverage criteria has
not been met.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically
necessary. Medicare rules also say that a seat elevation feature is non-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 expandable controller and seat
elevation feature. Our reviewer says that the requested expandable controller is not medically necessary. Our
physician reviewer found the clinical documentation provided does not show that the enrollee is unable to use
the standard switches for the wheelchair's power features. Additionally, the power seat elevator function is not
a covered feature.
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 expandable controller and seat elevation feature. have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311,
E2313) and a seat elevation feature (E2300) for a power wheelchair.