Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the complete series of intraoral x-rays (D0210), and the full mouth debridement (D4355) provided on October 2, 2019 by an out of network provider. You asked the Plan to pay for the dental services. You say that you were referred to the provider's office by the Plan. You also say that you were not aware that the provider that you were assigned to was not contracted with our plan. The Plan denied your request. The Plan says dental services that dental services that you receive out of network are not covered. The Plan says that there is no record of a phone call from you, nor the provider's office, prior to you receiving the services. 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 dental services that you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the complete series of intraoral x-rays (D0210), and the full mouth debridement (D4355) provided on October 2, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) provided by the out of network (OON) provider on February 4, 2020. You asked the Plan to issue reimbursement for the hearing aids. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) provided by the out of network (OON) provider on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond June 4, 2020. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary. 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on May 21, 2020 after a hospitalization for left knee and chest pain. You received oral medications and had stable vital signs. You were effectively treated for pain. You received physical and occupational therapy in the SNF and need assistance with walking 25 feet with a rolling walker. You need varied levels of assistance with activities of daily living. You have no skilled nursing needs or skilled therapy needs and do not require these services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond June 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional occupational therapy visits. You asked the Plan to pre-approve 8 additional occupational therapy visits. You say that the enrollee needs these services. The Plan denied your request. The Plan says additional visits are not necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 8 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has remained unchanged in her therapy progress from April 30, 2020 to May 6, 2020. She receives 24-hour supervision in her long term care facility and her functional level does not need the unique skills of a professional therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve8 additional occupational therapy visits.
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 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 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 you were medically stable with no evidence of need for supervision by a physical medicine rehabilitation (PMR) Physician or needs acute rehab nursing care. Your mobility is at supervision to contact guard assist (CGA) level. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Renflexis.You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis and chronic kidney disease. She has been on methotrexate and sulfasalazine. She has not tried and failed the Plan's required drugs of Inflectra or Remicade and Simponi Aria. The records do not support that the required drugs would be less effective or contraindicated; therefore, Renflexis is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Renflexis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing (0005U) provided on September 13, 2019. You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary. The Plan follows Medicare rules. Medicare rules say that one biomarker test is covered when the above criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested testing was not medically necessary. Our physician reviewer found that the case file does not contain documentation of a digital rectal exam, persistent elevation of the PSA, a multiparametric MRI, or major risk factors for prostate cancer. There is no documentation of relative contraindications for prostate biopsy. 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 testing have not been met.Therefore, we decided that the Plan does not have to pay for the testing (0005U) provided on September 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on December 2, 2019 by an out of network (OON) provider. You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 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 the x-ray services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 5, 2020 to January 7, 2020. You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says inpatient care was not necessary. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found while the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to expect that two midnights of inpatient level care would be medically necessary. The enrollee was evaluated for reported tachycardia. The enrollee was not tachycardic in the emergency department and her initial laboratory testing was non-actionable. While additional monitoring was reasonable, this could have been safely completed with the enrollee on observation status. In fact, the emergency department orders and the admission note indicate that the enrollee was to be on observation status. There is no documentation of new issues or complications arising. The care provided does not appear to have been medically necessary at the inpatient level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 5, 2020 to January 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from December 25, 2019 to December 30, 2019. You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges because you were admitted to the hospital. 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 $50 copayment for emergency care. The medical records show that you were not admitted inpatient after an ER visit from December 25, 2019 to December 30, 2019. Therefore, you are responsible to pay the $50 ER copayment. You have been asked to pay a $50 copayment for an ER visit. An ER visit falls within the emergency 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 ER visit provided from December 25, 2019 to December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital May 27, 2020 after multiple falls. Your condition improved and you were working with physical and occupational therapy. By June 2, 2020 you were walking 500 feet with one rest break and a rolling walker and are independent for transfers and activities of daily living. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader device. You asked the Plan to pre-approve a Freestyle Libre 14 day reader device. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Freestyle Libre 14 day reader device. Our reviewer says that the item is not medically necessary. Our physician reviewer found the plan requires that you use multiple insulin shots per day and adjust doses based on blood glucose levels in order to qualify for a CGM. You do not use insulin. In addition, you need to be monitoring 4 times per day and we only are told of 1 time per day checks. You do not meet all of the required criteria for Libre coverage. 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 Freestyle Libre 14 day reader device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on February 27, 2020. You asked the Plan to waive the coinsurance for the Part B injection. You say that you cannot afford to pay this amount. The Plan denied your request. The Plan says you have been charged 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 20% coinsurance for in-network Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. You have been asked to pay $1,977.18 which is 20% of the allowed amount for the Part B injection. The allowed amount is $9,885.88. ($9,885.88 x 20% = $1,977.18). The Part B 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 for the Part B injection provided on February 27, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the MRI of the abdomen provided by an in-network provider on March 19, 2020. You asked the Plan to pay for the MRI of the abdomen. The Plan denied your request. The Plan says that the services were provided prior to the review for authorization was completed. Medicare rules say that a contract provider is an agent of the plan. MA organizations have a responsibility to ensure that contracting physicians and providers know whether specific items and services are covered in the MA plan in which their patients are enrolled. In this case, the hospital where the MRI was provided is a contracted, in-network provider with the plan. Per Medicare guidelines, if a network provider furnishes a service to a MA beneficiary for a plan-covered service without following the plan's internal procedures (such as obtaining the appropriate plan pre-authorization), then the beneficiary should not be penalized to the extent the physician did not follow plan rules. Therefore, we decided that the Plan has to pay for the MRI of the abdomen provided on March 19, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Venofer 200mg/10ml vials. You asked the Plan to pre-approve the tier exception. You say that the drug is medically necessary and a tier exception is needed. The Plan denied your request. The Plan says a tier exception is not available for this type of drug. The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. We looked at the file and Medicare rules. Venofer is a Part B drug and is not eligible for tier exceptions. Based on this information, we decided that the Plan does not have to pre-approve a tier exception for Venofer 200mg/10ml vials.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve callus removal. You asked the Plan to pre-approve these services. You say that you need the procedure to eliminate future need for foot surgery. The Plan denied your request. The Plan says that routine foot care is not covered. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that routine foot care is not covered; however, the Evidence of Coverage (EOC) states that there is a supplemental benefit for routine foot care. The EOC clearly states that the plan covers up to 12 visits per year, limited to 1 visit per month, for non-Medicare covered routine foot care. The Plan has not provided any documentation to support why the supplemental benefit for routine foot care would not cover these services. Therefore, we decided that the Plan has to pre-approve callus removal. 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.