Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One.You asked the Plan to pre-approveSynvisc-One. You say that the requested Synvisc-One is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail the preferred drugs, Orthovisc and Monovisc, first.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 Synvisc-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. It is noted that treating physician prefers Synvisc over alternatives due to severity. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Synvisc-One. Based on the documentation provided, the enrollee has not tried and failed the required drugs. 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.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsuranceforthe triamcinolone acetonide injection provided on September 11, 2019.You asked the Plan to waive the coinsurance forthe triamcinolone acetonide injection. You say that ibuprofen does not work anymore. You say that the shot helps manage your pain. You The Plan denied your request. The Plan says the coinsurance applied 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 20% of the total cost for Medicare-covered chemotherapy drugs and other Medicare-covered Part B prescription drugs. You have been asked to pay $234.17, which is 20% of the allowed amount for the triamcinolone acetonide injection.The allowed amount is $1,170.83(20% x $1,170.83= $234.17).The triamcinolone acetonide injection falls within the "Medicare Part B prescription drugs"benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe triamcinolone acetonide injection provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the clinical documentation provided supports the need for LTACH care.The Plan denied your request. The Plan says the enrollee's care can continue to be safely managed in the current care setting. The Plan says that LTACH services are notmedically necessary.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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for recurrent colitis. The enrollee eventually underwent colon surgery, after which she developed respiratory failure. The enrollee has received a tracheotomy and remains on a ventilator. The enrollee is believed to have critical illness neuropathy, which will likely prohibit ventilator weaning for the next several weeks. There is no advantage in transferring the enrollee to theLTACH. The enrollee can remain at the current ACH until such a time that no acute services are required.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-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you will benefit from short-term rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF coverage. The Plan says that the enrollee has a high functional status and that her therapy needs can be met at a lower 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care with pneumonia and COPD exacerbation. She was treated with steroids, antibiotics, and nebs. Her prior level of function was living alone and modified independent with a walker with mobility and activities of daily living. Her current level of function is ambulating 590 feet with contact guard assist, transferring with contact guard assist, and minimal assist with lower body dressing. The records do not support that the enrollee needs daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing physical therapy and occupational therapy, the records do not support the need for daily therapy.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza Cap 8mcg.You asked the Plan to pre-approve Amitiza Cap 8mcg. You say that the medication is necessary.The Plan denied your request.The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.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 Amitiza Cap 8mcg.Benefits for Amitiza Cap 8mcgmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of an upper extremity joint.You asked the Plan to pre-approvean MRI. You say that this is medically necessary.The Plan denied your request. The Plan says this was not ordered by a physician.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI. Our reviewer says that this is not medically necessary at this time. Ourphysician reviewer found the medical records do not show any evidence of an order by a doctor for the requested MRI. Since the order is not present, the test is not justified 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 an MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of an upper extremity joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92014, 92015) provided on April 25, 2019 an by out of network provider.
You asked the Plan to pay for an eye exam. You say that you went to the same doctor a year ago and everything processed fine. You say you don't need a referral and you never received anything from the Plan that this doctor was never in-network. The Plan denied your request. The Plan says you must receive care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. The exceptions to this rule are emergent or urgently needed services, kidney dialysis services under certain circumstances and when the plan approves services prior to seeking care. A prior authorization request can be submitted by your doctor or you.
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 for an eye exam (92014, 92015) provided on April 25, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe treatment of swallowing dysfunction (92526) and the treatment of a speech disorder (92507) provided on August 18, 2019 to August 25, 2019.You asked the Plan to pay forthe treatment of swallowing dysfunction and the treatment of a speech disorder. You say that these services should be covered.The Plan denied your request. The Plan says these codes are not supported because the records are illegible.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 92526 is treatment of swallowing dysfunction and/ororal function for feeding and 92507 is treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the treatment of swallowing dysfunction and the treatment of a speech disorder. Our reviewer says that CPT codes 92526 and 92507 are not supported in the records. Our physician reviewer found the medical records provided for August 18, 2019, August 19, 2019, August 20, 2019 and August 25, 2019 do not include documentation of treatment of swallowing dysfunction and/or oral function for feeding or treatment of speech, language, voice, communication, and/or auditory processing disorder being provided. The documentation is illegible. Therefore, these services cannot be validated.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 treatment of swallowing dysfunction and the treatment of a speech disorder have not been met.Therefore, we decided that the Plan does not have to pay forthe treatment of swallowing dysfunction (92526) and the treatment of a speech disorder (92507) provided on August 18, 2019 to August 25, 2019.
Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to adjust the coinsurance for the ambulance transport. We decided that the Plan does not have to waive the coinsurance for the ambulance transport. You asked the Plan to waive the coinsurance for the ambulance transport. You say that you cannot afford this.The Plan says that that you are responsible for a 20% coinsurance.We decided that the Plan has to adjust the coinsurance for the ambulance transport. 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% coinsurancefor ambulance services.The file shows that the plan's allowed amount for these services was $394.92. A 20% coinsurance with regards to the allowed amount is $78.98. The coinsurance the plan is charging is above this amount.Therefore, we decided that the Plan has to adjust the coinsurance for the ambulance transport. 
We also decided that the Plan does not have to waive the coinsurance for the ambulance transport.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 the ambulance transport.Therefore, we decided that the Plan does not have to waive the coinsurance for the ambulance transport.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you by "the provider" on December 6, 2018 to July 1, 2019.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 provider is not Medicare-certified.The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay forthe services rendered to you on December 6, 2018 to July 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on August 23, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.
The Plan must follow Medicare rules. Medicare rules say that all information must corroborate the documentation in the record and support that coverage criteria are met. In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 26, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.
The Plan must follow Medicare rules. Medicare rules say that all information must corroborate the documentation in the record and support that coverage criteria are met. In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 26, 2019 by an out-of-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 referring provider 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 for the laboratory services provided on September 26, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 29, 2018 by an out of network provider.
You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no authorization on file for the service billed.
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. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 29, 2018 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 19, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 19, 2019.