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

We decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471) provided on February 18, 2020.
You asked the Plan to pay for a shingles vaccine and administration. You say that you were not informed you would be charged for this vaccine. The Plan denied your request. The Plan says this vaccine is covered only under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471) provided on February 18, 2020.
Benefits for a shingles vaccine and administration 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a skilled nursing facility. A less intensive, longer duration of therapy is appropriate.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 15, 2019 to
October 17, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital care was not medically necessary.
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 enrollee was brought to the Emergency Department (ED) on October 15, 2019 and was subsequently admitted to medical-surgical inpatient with an abnormal electrocardiogram (ECG) and dehydration. The attending physician wrote an order on October 16, 2019 to discharge the patient when arrangements were completed. The enrollee was discharged home with hospice on October 17, 2019. The review has determined 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 October 15, 2019 to October 17, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH are not met.
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 receiving appropriate care which she will need to be prolonged somewhat if a PEG tube is to be placed, however, if not, discharge to a lower level of care appears appropriate at this time. The enrollee does not require any services at the LTACH that are not already available at the current acute care facility. Therefore, this request for LTACH transfer is not sufficiently supported and will be considered not medically necessary 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 for enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Monovisc injections (J7327).
You asked the Plan to pre-approve the Monovisc injections. You say that the enrollee appears to be an excellent candidate for Monovisc injections to improve pain, range of motion, and functional mobility and potentially postpone the need for future knee arthroplasty. The Plan denied your request. The Plan says that there is no documentation that the enrollee has tried Synvisc/Synvisc One or Euflexxa injections. The Plan also says that if the first Monovisc injection provided limited benefit, further injections may also not be beneficial.
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 the Monovisc injections. Our reviewer says that the Monovisc injections are medically reasonable and necessary. Our physician reviewer found the enrollee received a Monovisc injection to the right knee on January 6, 2020 with reduction in pain from grade 7/10 to 4/10 as of March 5, 2020 with reported improvement in range of motion and functional mobility. There is no evidence that the enrollee had tried and failed the Health Plan's step therapy requirement, or that the required drugs would be less effective and/or less likely to have adverse effects for the enrollee. Our reviewer found that in this case, the Health Plan's step therapy requirement would not apply as the enrollee is receiving on-going Monovisc therapy. Our physician reviewer also found that there is evidence of pain reduction and functional benefit with the prior Monovisc injection with subsequent recurrence of pain and functional limitation. 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 Monovisc injections have been met. Therefore, we decided that the Plan has to pre-approve Monovisc injections (J7327).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says care can be received in another setting, such as home, a long-term care facility, or other outpatient setting.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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Part B injectable drugs received on January 16, 2020.
You asked the Plan to waive the coinsurance for the drugs. You say that you thought this would be covered in full. The Plan denied your request. The Plan says the claim processed and assessed the correct cost-sharing.
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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the drugs. The drugs fall within the Medicare Part B 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 coinsurance for Part B injectable drugs received on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete denture - maxillary (D5110) provided on January 8, 2020.
You asked the Plan to pay for the dental services. You say that you were not advised that your dentures would not be covered. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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 requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for complete denture - maxillary (D5110) provided on January 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says Rituximab, although classified as an antineoplastic agent, is not being used for a cancer condition in this instance.
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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the Medicare-approved compendia do not support the use of Rituximab for treatment of autoimmune encephalitis as either an FDA-approved or off-label use. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional rental payments for a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve the additional rental payments of the CPAP. You say that the enrollee should be approved to have additional payment made on his behalf for this CPAP device since there has been a change in payer. The Plan denied your request. The Plan says 13 rental payments have already been made for this CPAP device which was originally provided in February 2017.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee received the current CPAP device on February 1, 2017. The supplier confirmed that this was converted to sale in November 2018. This means that the enrollee currently owns the CPAP device at issue in this case. Additional rental payments for a device which the enrollee owns are not covered by Medicare. There is no information presented to indicate that a new CPAP is required. Therefore, we decided that the Plan does not have to pre-approve additional rental payments for a continuous positive airway pressure (CPAP) device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the care can be received in other settings, such as skilled nursing facility, home with home health, and home physical therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is medically stable and does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While she may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient clinic visits and ER visits provided on April 2, 2019 to November 5, 2019.You asked the Plan to waive the copayments for outpatient clinic visits and ER visits. You say that you disagree with the charges because you expected that you were paid for.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 $40 copayment for specialist visits a $90 copayment for emergency care. You received outpatient clinic visits from April 2, 2019 to November 5, 2019 for a total of 8 visits. Therefore, you are responsible to paya $40 copayment per each visit. The total amount you owe for outpatient clinic visits is: $320.You received ER visits from April 2, 2019 to November 5, 2019 for a total of 2 visits. Therefore, you are responsible to pay a $90 copayment per each ER visit. The total amount you owe for ER visits: $180. The total amount you owe is: $500.You have been asked to pay the total copayment amount of $500 for outpatient clinic visits and ER visits. Outpatient clinic visits fall within the physician/practitioner services, including doctor's office visits benefit category. ER visits fall within the emergency care 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 outpatient clinic visits and ER visits provided on April 2, 2019 to November 5, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a knee repair procedure (29881, 29888, 29880, 29882). You asked the Plan to pre-approve the surgical procedure. You say that the surgery is medically necessary to repair the enrollee's injury to the left knee. The Plan denied your request. The Plan says that the requested procedure is not medically necessary. 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 the surgical procedure. Our reviewer says that the requested procedure is medically appropriate and necessary. Our physician reviewer found that the literature suggests that physiological age and activity level are more important than chronological age as deciding factors when considering ACL reconstruction. This enrollee presents with persistent left knee pain with associated popping and instability following a fall. Clinical exam findings are consistent with imaging evidence of a complete ACL rupture, complete medial meniscus tear, and partial lateral meniscus tear. The enrollee has failed to improve with reasonable conservative treatment, including hinged bracing, activity modification, ice, and anti-inflammatory medication. This request for left knee arthroscopic ACL reconstruction, partial lateral meniscectomy, and partial medial meniscectomy is medically reasonable and necessary for treatment of the enrollee's medical 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 surgical procedure have been met. Therefore, we decided that the Plan has to pre-approve a knee repair procedure (29881, 29888, 29880, 29882).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest rendered on January 4, 2020.You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.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 $150 copayment for in-network advanced imaging services. Review of the file shows that you received a CT scan of the chest on January 4, 2020. You have been asked to pay a $150 copayment for these services. These services fall within the in-network 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 the computed tomography (CT) scan of the chest rendered on January 4, 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 the IRF services are medically necessary. The Plan denied your request. The Plan says you can safely receive the services you need in alternate levels of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at an alternate level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at an alternate level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.