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

We decided that the Plan does not have to pre-approve Gel-One 30mg/3ml.

You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied
your request. The Plan says a trial of 3 months of physical therapy is required before Gel-One can be
considered.

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 Gel-One. Our reviewer says that the
Gel-One is not medically necessary. Our physician reviewer found there is no record of the plan's preferred
treatment being trialed, or any reason the plan's preferred treatment would be unsafe or ineffective for the
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 Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One 30mg/3ml.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a lumbar spinal fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervical spine surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided December 17, 2020.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says this service has already been paid on this date. The records do not support multiple units.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 71045 are not supported in the medical record. The medical record only supports 1 units of CPT code 71045. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that needed care can be safely given in 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for nausea, weakness
and acute kidney failure. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on December 9, 2020.

You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says this visit exceeds the benefit limit.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided on February 12, 2020, less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis service (90960) provided on June 1, 2020.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service 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 20% coinsurance for each in-network Medicare-covered dialysis service and a 45% coinsurance for each out-of-network Medicare-covered dialysis service provided.

You have been asked to pay $61.67 (Plan allowed amount of $308.35 x 20% coinsurance) for the out-of-network Medicare-covered dialysis service provided. This amount is less than the applicable coinsurance as the claim was processed by the Plan at the in-network Medicare-covered rate. 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 the dialysis service (90960) provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the waterproof tape (A4452), collagen dressings (A6021), gauze (A6402), and the light compression bandages (A6449) provided on October 27, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the records provided do not support the billed items in this case.
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a physician order and proof of delivery. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have been met. The additional information provided contains a valid invoice and proof of delivery for the supplies billed in this case. This is confirmation that the items were shipped on the billed date of service. Therefore, we decided that the Plan has to pay for the waterproof tape (A4452), collagen dressings (A6021), gauze (A6402), and the light compression bandages (A6449) provided on October 27, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services provided on May 1, 2019 to August 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient surgery services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the outpatient surgery services provided on May 1, 2019 to August 3, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
January 14, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like to
appeal this service. The Plan denied your request. The Plan says this service is not covered.
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
problem focused limited oral evaluation provided on January 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 3, 2021.

You asked the Plan to waive the copayment for the ambulance ride. You say that you were not supposed to be picked up by an ambulance. 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 $200 copayment for each one-way Medicare-covered ambulance transport for in- and out-of-service areas. 

You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls 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 ride provided on January 3, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Infed 100mg/2 ml vial.

You asked the Plan to pre-approve Infed. You say that Infed is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Infed. Our reviewer says that Infed is medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is documentation that the Infed is safe and effective for the patient. Although the health plan argues that the patient's hemoglobin, mean corpuscular volume and ferritin levels are not low enough based on their prior authorization criteria, records do show the patient has iron deficiency anemia for which use of the Infed is approved by the Food and Drug Administration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Infed have been met. Therefore, we decided that the Plan has to pre-approve Infed 100mg/2 ml vial.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.

You asked the Plan to pre-approve SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says the member does not neet daily skilled services provided on on an inpatient basis in an SNF.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from
November 18, 2020, through December 17, 2020
You asked the Plan to waive the copayment for the physical therapy. You say that you should not have to pay for these service as they were unnecessary. The Plan denied your request. The Plan says the claims processed correctly according to the 2020 benefit plan design.
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 $35 copayment for outpatient rehabilitation services. You have been asked to pay $35 copayment for the physical therapy. The physical therapy falls within the outpatient rehabilitation 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 physical therapy provided from November 18, 2020, through December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on March 18, 2020.

You asked the Plan to pay for the panoramic x-ray. You say that you were told that you needed to go to this dentist because other offices were closed due to COVID-19. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, panoramic or diagnostic x-rays are limited to one procedure every five years. The record shows that you received a panoramic x-ray on March 31, 2020 and your panoramic or diagnostic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (CPT 99204) provided to the enrollee on November 9, 2020.
You asked the Plan to pay for the visit. You say that this should be reconsidered, and reimbursement should be allowed. The Plan denied your request. The Plan says the enrollee previously saw the same provider within the past three years.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a moderate level of decision making." We find that CPT code 99204 is not supported in the medical record. Specifically, the enrollee should not be considered a "new patient." The enrollee previously saw the same provider within 3 years of the denied date of service on January 15, 2019. This would not qualify the enrollee as a "new patient" according to Medicare and coding guidelines. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (CPT 99204) provided to the enrollee on November 9, 2020.
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 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 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 there are no services at the LTACH that the enrollee 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. Transfer may be considered when treatment has completed and the enrollee is more stable. 

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.