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

We decided that the Plan does not have to pay for the services rendered on August 16, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until September 4, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services rendered on August 16, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the eye exam you had on October 2, 2019.You asked the Plan to waivethe copayment. The Plan denied your request. The Plan says you are responsible for the copayment.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 $10 copayment for each optometry visit. Review of the file shows that you had an office visit for an eye exam on October 2, 2019. You have been asked to pay a $10 copayment for the visit. The visit falls within the vision 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 waivethe copayment for the eye exam you had on October 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/3/20with a history of dementia and Parkinson's. The chief complaint is multiple falls and increased urination and change in behavior. His head CT was negative for a bleed. He was treated for a urinary tract infection (UTI). On 2/10/20 he ambulated 100 feet with contact guard assist for safety with intermittent visual cues. He needed supervision for supine to sit and standby assist for sit to stand with a rolling walker. He was maximum assist for sit to stand x 2. Therapy notes he is grossly supervision/contactguard assist for steadying with intermittent visual cues for safety. He is limited by fatigue. The enrollee's prior level of function was he needed activities of daily living assist and assist with all transfers. He uses a rolling walker for mobility and has a first floor set up. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for home health care services provided by an out-of-network provider from July 1, 2019 to July 16, 2019.You asked the Plan to waive the deductible forout of network home health services. You say that you were not informed the enrollee had switched insurance.The Plan denied your request. The Plan says this claim processed 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 there is a $1000 deductible for out-of-network services. The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for out-of-network services. This cost sharing is a contractual obligationthat had not been met at the time out of network home health services was received on July 1, 2019 to July 16, 2019.Therefore, we decided that the Plan does not have to waive the deductible forhome health care services provided by an out-of-network provider from July 1, 2019 to July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation and injection for the enrollee.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the enrollee has not been treated with a 3-month trial of conservative therapy.The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the rationale for the ablation and sclerotherapy procedure is not included in the materials provided. It is noted that since his procedure was scheduled he developed pain, swelling and erythema. There is no documentation of a duplex since his episode was treated-it is possible the patency of the greater saphenous vein has changed as his episode may have been phlebitis. A duplex examination describing reflux in the vein to be treated is not included in the materials provided. Additionally, the most recent documentation describes resolution of pain and decrease in swelling. There is no documentation provided indicating lifestyle or mobility limiting pain that persists despite a concerted effort at conservative treatment. There is documentation of an abnormal LE pulse examination that is unaddressed. Based on these findings, the requested services are 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approveendovenous ablation and injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Repatha 140 mg/ml syringe medication (J3590).You asked the Plan to pre-approvethis medication. You say that you are requesting reconsideration of the Plan's denialas the medication is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee has a medical (MA) only policy with the plan, not a Prescription DrugPlan (PDP). Therefore, drug coverage for the enrollee is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Repatha 140 mg/ml syringe medication (J3590).Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 21, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat 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 physician's services provided on August 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that additional therapy is needed for the enrollee to gain her strength.The Plan denied your request. The Plan says that there are no skilled nursing needs or skilled therapy needs identified that require the requested 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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria forSNF services.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-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric treatment beyond January 23, 2020.You asked the Plan to pre-approvethe continued inpatient psychiatric care. You say that the enrollee would be a danger to herself and others in a less restrictive setting.The Plan denied your request. The Plan says care in the inpatient setting is no longer needed.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric care. Our reviewer says that the continued inpatient stay is not considered medically reasonable and necessary. Our physician reviewer found this 56-year-old female was admitted to the acute inpatient psychiatric hospitalization on January 2, 2020 with Schizoaffective Disorder Bipolar Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations without any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 24, 2020 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was without aggressive behaviors.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 continued inpatient psychiatric care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric treatment beyond January 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are skilled nursing and therapy needs, butthey do not need to be provided on a daily basis. The enrollee's care can be appropriately provided through home-based and outpatient services. If stair climbing is an issue, this would most appropriately occur on the actual stairs in the home setting. Rearrangement of the living space (e.g. setting up a bed on the first floor) or use of adaptive equipment (e.g. commode) would be examples of ways in which a stair climbing deficit could be 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approve IRF care. You say that given the enrollee's condition, she would be best treated in the IRF setting and that less intensive therapy would not be sufficient.The Plandenied your request. The Plansaysshe has no acute medical conditions which require the IRF 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 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 suffered a fall in the home on 1/30 and was seen in the ED. The patient was medically stable with no evidence of need for supervision by a PMR physician or need for acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability.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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 12/27/19 after complaint of shortness of breath and weakness for a few days. She had a recent hospital stay on 12/16/19 for right pleural effusion with thoracentesis and discharged home on 12/21/19. The enrollee most recently has undergone VATS procedure and dialysis access was placed 12/30/19 due to worsening renal function. She is debilitated, but recent records indicate she is stabilizing. Hemodynamics are stable. Hemoglobin and hematocrit are stable. The enrollee is at a maximum/total assist needed for care. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly maximum/total assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 6, 2019 by an out-of-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating 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 has network providers available who can provide 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 forthe medical services provided on September 6, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.You asked the Plan to pre-approve Hymovis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Hymovis. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has adiagnosis of unilateral primary osteoarthritis of the left knee. The documentation does not support that the enrollee has tried Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. The enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met.Therefore, we decided that the Plan does not have to pre-approveHymovis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan topre-approveSNF services. You say that delay will contribute to enrollee complications.The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or nursing services.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 SNF services. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have tube, enteral complex wound care or other SNF level skilled nursing need. This enrollee does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient has not fully participated in therapy. He does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.