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

We decided that the Plan does not have to waive the copayment for skilled nursing facility services you received from February 6, 2021, to February 28, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you were advised by the social worker that additional days at the nursing facility would be at no extra cost. You say that had you known there would be an additional cost, you would have chosen to go home. 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 $0 copayment for days 1-20 and a $184 copayment per day for days 21-100 for skilled nursing facility services.
Records show that you were in the nursing facility for 23 days between February 5, 2021, and February 28, 2021. You were charged $0 for days 1-20. For the remaining three days, you were charged a copayment of $184 per day, for a total of $552. 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 skilled nursing facility services you received from February 6, 2021, to February 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 25, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on August 25, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 MG/ML Syringe (CPT code J0897), for the
enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says Part B coverage of Prolia is subject to their step therapy criteria, which requires
ONE of the following to be met: EITHER, a history of osteoporosis-related fracture; OR, the enrollee has
failed, or has a contraindication to zoledronic acid (our preferred step therapy drug). The Plan states there is no
indication the enrollee has had an osteoporosis-related fracture. The Plan states the enrollee has not tried and
failed zoledronic acid and there is no indication zoledronic acid, an intravenous (IV) isphosphonate drug,
would likely be: less effective, and/or cause adverse effects for the enrollee. The Plan states for a step therapy
exception to be granted, the provider needs to tell the Plan: if the enrollee is already using Prolia; OR, why
zoledronic acid would be contraindicated.
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 medication. Our physician reviewer
found the provided records did not show documentation of a trial and failure of zoledronic acid infusion. There
was no indication that the enrollee would not tolerate or not have sufficient effectiveness from zoledronic acid
which is an infusion not an oral bisphosphonate derivative which is generally more tolerable than oral.
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 medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia 60 MG/ML Syringe (CPT code J0897), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the cataract surgery. You say that this service was approved earlier in the
year but was never done due to an accident. 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
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-plan provider.
You asked the Plan to pre-approve these services. You say that you want to see a doctor outside of the network. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to a non-plan provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement service (11043) and the office visit (99213) rendered by the out-of-network (OON) provider on March 24, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the debridement service (11043) and the office visit (99213) rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V (F5) genetic testing.
You asked the Plan to pre-approve F5 genetic testing. You say that the COVID-19 vaccine may cause blood clots in people with the Factor V Leiden gene, so this testing is a crucial in a decision of whether or not to get this vaccine. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the scientific literature does not support screening for Factor V Leiden in the context of COVID-19.
The Plan must follow Medicare rules. Medicare rules say that Factor V genetic testing is only covered for evaluation of venous thromboembolism. We looked at the file and Medicare rules. This testing is not covered for the requested screening purposes. Based on this information, we decided that Medicare rules for coverage of F5 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor V (F5) genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Percutaneous Lumbar decompression procedure (0275T).
You asked the Plan to pre-approve the Percutaneous Lumbar decompression procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says this procedure is only covered when the enrollee is part of a clinical trial or study.
The Plan must follow Medicare rules. Medicare rules say that Percutaneous laminotomy/laminectomy is covered when the beneficiary is enrolled in a clinical trial or study. We looked at the file and Medicare rules. The record does not show the enrollee is enrolled in a clinical trial or study. Based on this information, we decided that Medicare rules for coverage of the Percutaneous Lumbar decompression procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Lumbar decompression procedure (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 20, 2021, to January 25, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that due to recent health issues you are having financial difficulties and request a reduction in charges. 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 $250 copayment for days 1-5 for inpatient hospital care. 

You had an inpatient hospital stay from January 20, 2021, to January 25, 2021. Therefore, you are responsible to pay a $250 copayment for days 1-5 (January 20, 2021, to January 24, 2021). $250 (copayment) x 5 (inpatient days) = $1,250. 

You have been asked to pay the total copayment amount of $1,250 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 copayment for an inpatient hospital stay provided from January 20, 2021, to January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480, 80307) provided on February 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you would like the claim reviewed and reconsidered for payment. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 drug testing (G0480, 80307) provided on February 25, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutritional supplements.  
 
You asked the Plan to pre-approve nutritional supplements. You say that nutritional supplements are medically 
necessary. The Plan denied your request. The Plan says nutritional supplements, any brand, are not covered by 
the Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate for you to use, neither Medicare nor the Plan provides coverage for them. Therefore, we decided 
that the Plan does not have to pre-approve nutritional supplements for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy for gynecomastia.

You asked the Plan to pre-approve a mastectomy for gynecomastia (19300). You say that you need this procedure because weight loss is not helping. The Plan denied your request. The Plan says the enrollee is asymptomatic for gynecomastia.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a mastectomy for gynecomastia (19300). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not show that the patient has fully exhausted first line strategies to treat their condition including exercise and dietary modification to justify this elective procedure. Therefore, as the patient is asymptomatic and has not failed first line treatment strategies, this request for mastectomy 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 a mastectomy for gynecomastia (19300) have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy for gynecomastia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you were unaware a prior authorization was needed, and this service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was also out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on March 5, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture.
You asked the Plan to pre-approve the partial denture. You say that you would like reconsideration because you lost your partial denture and need it to eat. The Plan denied your request. The Plan says this service is limited to once every five plan years.
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.
We looked at your request, the file and Plan rules. Based on this information we have decided that Plan criteria for coverage have not been met.
Specifically, the record indicates that you received a partial denture on December 6, 2018. Partial dentures are covered once every five plan years. Therefore, we decided the Plan does not have to pre-approve the requested partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been 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 patient is an 82-year-old male who was admitted to the current acute care hospital with acute hypoxic respiratory failure from CHF and pneumonia. He was intubated and treated with antibiotics, and diuresis. The patient appears to be unstable requiring trach for airway stabilization in the setting of throat cancer. Additional short-term acute care services are required which can safely be received at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility.
Therefore, this request for LTACH services will be considered not medically necessary at this time as transfer would provide a clinical advantage. Transfer may be considered when the patient is more stable and when treatment has completed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FREESTYLE LIBRE 14 DAY SENSOR continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your request. The Plan says they were unable to determine medical necessity based on the documentation submitted.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pre-approve a FREESTYLE LIBRE 14 DAY SENSOR continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services you received from March 1, 2021, to March 5, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you were advised by the social worker that additional days at the nursing facility would be at no extra cost. You say that had you known there would be an additional cost, you would have chosen to go home. 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 $0 copayment for days 1-20 and a $184 copayment per day for days 21-100 for skilled nursing facility services.
Records show that you were in the nursing facility for 23 days between February 5, 2021, and February 28, 2021. You were charged $0 for days 1-20. For the remaining three days in February, you were charged a copayment of $184 per day, for a total of $552. Then, from March 1, 2021 to March 5, 2021, you were charged a $184 copayment per day for four days, for a total of $736. 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 skilled nursing facility services you received from March 1, 2021, to March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you are the only one who offers insulin infusion therapy as treatment for metabolic disorders within a 50 mile radius of the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit to be provided by an out-of-network (OON) provider.