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

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on March 30, 2021.

You asked the Plan to waive the copayment for the podiatry visit. You say that you should have a $0 copayment because you have been diagnosed with pre-diabetes and venous insufficiency. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each in-network Medicare-covered visit. 

You have been asked to pay a $45 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The record shows you were only charged for the office visit, which included a hammer toe diagnosis of the right and left foot and generalized edema.

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 podiatry visit provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria for IRF care are not 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 the complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 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 medical records show the enrollee the enrollee was admitted with colitis and ileus and found to have a gastrointestinal bleed from ischemic colitis. The enrollee was intubated for airway protection and now has a tracheostomy. The enrollee continues to receive acute care services, and these have not been denied.

The medical record does not indicate that the enrollee requires services from an LTACH that he is not currently receiving at the current facility. Criteria required for transfer are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received October 16, 2020.

You asked the Plan to pay for the crown. You say that you are seeking reimbursement for any amount unpaid amount by your primary insurance. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

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. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received October 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI of the brain (70551) provided on February 26, 2021.

You asked the Plan to waive the copayment for an MRI of the brain. You say that you do not understand why the Plan is not paying anything towards this service. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $275 copayment for outpatient hospital services including diagnostic radiology.

You have been asked to pay a $241.19 copayment for an MRI of the brain. The EOC confirms $275 is the required copayment for this service. You have been asked to pay a copayment of $241.19, which is less than the Plan's contracted amount. An MRI of the brain 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 a magnetic resonance imaging (MRI) of the brain (70551) provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the eye exam, visual field exam and ophthalmic imaging provided on January 22, 2021.

You asked the Plan to waive the deductible for the eye exam, visual field exam and ophthalmic imaging. You say that you are requesting an appeal for payment. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your combined in-network and out-of-network medical deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Vision Care" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 deductible applies to vision services and outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the eye exam, visual field exam and ophthalmic imaging were received on January 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the eye exam, visual field exam and ophthalmic imaging provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve molecular pathology testing services.

You asked the Plan to pre-approve the requested services. You say that it is important to prevent any life-threatening blood clots in the future. The Plan denied your request. The Plan says this is not a Medicare-covered screening test.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. The records show that there is a family history of a clotting disorder. There is no documentation of a personal history of a clotting disorder. The requested testing services are being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve molecular pathology testing services.
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 you will get better care at the IRF than at another facility. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level 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 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet block injections.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that facet blocks are covered when specific criteria are met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you had a previous spinal fusion surgery. The records show you developed back pain after activity in April of 2021. You were treated for muscle spasms and pain. There are no further records. The records do not show that the pain was present for three months or that it failed conservative therapy. The criteria for coverage are not met and the facet block injections are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet block injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).

You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the services is helpful for the enrollee's health problem.

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 genicular nerve radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 82-year-old woman has chronic right knee pain after a right total knee arthroplasty. In this case, cooled radiofrequency ablation is considered experimental/investigational. In addition, genicular radiofrequency ablation is the subject of on-going clinical trials. Therefore, this request is deemed not medically reasonable and 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 genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.

You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says the policy considers this request experimental and investigational.

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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block of the left knee 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 the blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).

You asked the Plan to pre-approve the SSBCI benefit. You say that you need these services. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefit for the Chronically Ill for 2021.

Medicare generally does not cover supplemental benefits. However, the Plan offers a special supplemental benefit for the chronically ill (SSBCI) that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SSBCI benefit have not been met. Specifically, the record does not show that you have been diagnosed with any of the qualifying diagnoses. Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and audiology tests to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit and audiology tests. You say that you have been a patient for ten years and you follow up with him twice a year to renew your medication and evaluate your hearing. You say that the specialist you are being referred to specializes in children and you request to continue to see your doctor at the in-network rate. The Plan denied your request. The Plan says in-network providers are available.

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 office visit and audiology tests to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have knee pain. The use of genicular nerve blocks is considered experimental/investigational in nature and are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
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 LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 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 medical records show you were admitted with small bowel obstruction and required parastomal hernia repair, and loop ileostomy. Postoperatively you developed pneumonia. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services at an LTACH that cannot be provided by the current facility. Medicare coverage criteria for transfer are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard test 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 the enrollee is symptomatic and above the age limit.

The Plan must follow Medicare rules. The rules say that the Cologuard test is covered for enrollees between 50 and 85 years. 

The enrollee is above the age limit for this at 89 years old. 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 the Cologuard test for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Anoro Ellipta for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is a necessary breathing medication. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Anoro Ellipta for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.