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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's
needs can be provided at an alternative level of care.
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 physician reviewer
found that the enrollee is limited due to pain, but otherwise appears at functional baseline. She is medically
stable. She does not have any complex daily wound care, parenteral medications, or requires care for a feeding
tube. Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care. Therefore, an admission to a SNF for
inpatient skilled rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient admission for an elective total hip replacement.
You asked the Plan to pre-approve the inpatient admission. You say that it is felt that inpatient admission would be most appropriate. The Plan denied your request. The Plan says there is no indication this surgery will require a two-midnight hospital stay. As such, outpatient admission is reasonable at this time.
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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our
physician reviewer found the documentation indicates that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The arthroscopy procedure is currently approved as an ambulatory outpatient procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient admission for an elective total hip replacement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no knee instability demonstrated on exam.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has varus and valgus knee deformities due to osteoarthritis. The provided documentation includes a physical examination that does not document knee instability. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1843) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital admission.
You asked the Plan to pay for an inpatient hospital admission. You say that inpatient care is medically necessary following this major surgery. You say that, once in the hospital, there will be instruction on how to function while healing from the hip surgery. The Plan denied your request. The Plan says the guidelines for coverage of an inpatient stay have not been met. The Plan says that the approved elective left total hip arthroplasty can be provided in an outpatient setting.
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 an inpatient hospital admission. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of the request for an inpatient admission the requesting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. The enrollee was being treated for unilateral primary osteoarthritis of the left hip. She presented with debilitating pain in the left hip that is limited her quality of life. She wishes to proceed with a total hip arthroplasty. Exam reveals external rotation contracture. She has been planned to undergo a left direct anterior approach total hip arthroplasty on July 12, 2021. However, detailed documentation is not evident regarding significant co-morbidities that would warrant a pre-authorized inpatient admission expected to be greater than two midnights. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for inpatient admission for left total hip arthroplasty is not medically reasonable or necessary based upon available clinical data. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 14, 2021.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the hearing aid benefit is administered by the Plan's hearing aid provider.

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. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's participating hearing aid provider. 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 hearing aids provided on March 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) on February 11 and February 23, 2021.
You asked the Plan to waive the copayment for the ambulance service. You say that there should only be one copayment for the two ambulance trips because they were for the same issue. The Plan denied your request. The Plan says the correct cost share applied to the claims.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for Ambulance Services. You have been asked to pay a $450 copayment ($225 per each Medicare covered one-way trip) for the ambulance service. The ambulance transportation fall within the Ambulance 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 ambulance service, basic life support, non-emergency
transport (A0428) on February 11 and February 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit (G0463) provided on February 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an OON outpatient clinic visit. You say that the enrollee benefited from this service. The Plan denied your request. The Plan says this was 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 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 an outpatient clinic visit (G0463) provided on February 19, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Photofrin Injection.
You asked the Plan to pre-approve Photofrin, Injection, porfimer sodium, 75 mg (J9600). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says this treatment is considered untried for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Photofrin, Injection, porfimer sodium, 75 mg (J9600). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the requested use of Photofrin is Food and Drug Administration-approved for the enrollee's diagnosis. Based on the medical records provided, the Medicare-approved major drug compendia, clinical research that appears in a CMS-approved medical journal and guidelines of the National Comprehensive Cancer Network there is no documentation that supports use of Photofrin for metastatic medullary thyroid carcinoma. Based on the medical records provided and the Medicare-approved major drug compendia and guidelines of the National Comprehensive Cancer Network there is no documentation that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Photofrin, Injection, porfimer sodium, 75 mg (J9600) have not been met. Therefore, we decided that the Plan does not have to pre-approve Photofrin Injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient dialysis services provided by a participating provider on March 1, 2021, to April 30, 2021.

You asked the Plan to waive the coinsurance for outpatient dialysis services. You say that you already met your out-of-pocket max. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for services to treat kidney disease/outpatient dialysis treatments. 

You have been asked to pay a 20% coinsurance of the allowed amount for outpatient dialysis services. The total allowed amount is $637. The total amount you are being asked to pay is $127.40 ($637 x 20% = $127.40). At the time of these services your out-of-pocket maximum had not been met; therefore, the correct coinsurance has been applied. Outpatient dialysis services falls within the services to treat kidney disease/outpatient dialysis treatments 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 outpatient dialysis services provided by a participating provider on March 1, 2021, to April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered as it is not primarily medical in nature.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested E2311 is not medically necessary as the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The wheelchair includes power tilt and recline and power elevating leg rests. The enrollee does not need a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee 's strength and function in the upper extremities with the ability to use the on/off switch on the power wheelchair assessment indicates that the enrollee can control any power options through their own individual switches and does not require the E2311. The power seat elevation feature (E2300) is not medically necessary as it is not primarily medical in nature. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for and waive the copayment for an office visit, x-ray, ultrasound therapy, and manual manipulation provided on March 16, 2021.
You asked the Plan to pay for and waive the copayment for office visit, x-ray, ultrasound therapy, and manual manipulation. You say that you had terrible pain, and if you did not have these services it would have cost the Plan more for a hip replacement.
The Plan denied your request. The Plan says the denial of payment for the office visit, x-ray, and ultrasound therapy is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that the copayment amount you are being charged is correct.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 copayment for Medicare-covered chiropractic services. The records show that the office visit, x-ray, and ultrasound therapy at issue are not manual manipulation of the spine. You are also responsible for $20 copayment for the covered manual manipulation service. Therefore, we decided that the Plan does not have to pay for and waive the copayment for an office visit, x-ray, ultrasound therapy, and manual manipulation provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the infectious disease office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the infectious disease office visit. You say that you want to see this provider so all your specialists will be in one place. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the infectious disease office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy (43239) provided January 18, 2021 to January 20, 2021.

You asked the Plan to waive the copayment for the endoscopy. You say that you were never told there was a copayment. The Plan denied your request. The Plan says the correct copayment was applied. The endoscopy performed was not a screening colonoscopy.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Outpatient Hospital Services. 

You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the Outpatient Hospital 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 endoscopy (43239) provided January 18, 2021 to January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical radiofrequency ablation.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there needs to be two medial branch blocks on each side that each provided 80% relief of pain.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you underwent a first set of diagnostic cervical medial branch blocks with 50% pain relief achieved. The request does not meet the 80% pain relief criteria for two sets of blocks and therefore, the request is deemed not medically reasonable or necessary. Further, the presence of cervical radiculopathy has not been addressed.
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve these services. You say that you have no other means of transportation to your medical appointments. The Plan denied your request. The Plan says you have exhausted the benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from March 2, 2021, through March 31, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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 $0 copayment per day, for days 1-20 and a $184 copayment per day, for days 21-100, for in-network skilled nursing facility care.

You have been asked to pay $1,840 ($184 copayment x 10 days) for the in-network inpatient skilled nursing facility care provided. 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 inpatient skilled nursing facility (SNF) care provided from March 2, 2021, through March 31, 2021.