Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to make additional payment forthe office visit provided on September 18, 2019.You asked the Plan to make additional payment for the office visit. You say that you feel that this should be covered by the Plan.The Plandenied your request. The Plan says that the primary payer has paid $214.62 for this visit applying a $40 copayment. The plan would only have paid $163.52 and the enrollee has a $40 copayment. Since the provider was paid more than the plan would have paid,no further payment is needed.The Plan must follow Medicare rules. Medicare rules say that secondary payment is calculated based on the above referenced formulas. In this case, formula #1 would be: the billed amount ($416) less the primary payment ($214.62) for a payment of $201.38. Formula #2 is:  $163.52 less the plan copayment of $40 for a payment of $123.52 which is what the plan would have reimbursed if there were not primary. Formula #3 is: the primary allowable ($254.62) less the amount paid ($214.62) for a total of $40. In this case, $40 is the lowest and is what the plan must pay to the provider. It should be noted that since the provider billed the primary payer, they are not required to accept $214.62 as payment in full as their contract with the plan does not apply. The Plan must pay the difference between the amount allowed by the primary payer and the amount paid by the primary payer, up to the amount for which the Plan would have been responsible if there were no primary payer. Therefore,we decided that the Plan has to make additional payment forthe office visit provided on September 18, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa 20mg/2ml syringe.
You asked the Plan to pre-approve Euflexxa 20mg/2ml syringe. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been 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 Euflexxa 20mg/2ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) 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 Euflexxa 20mg/2ml syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa 20mg/2ml syringe.
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-approve IRF 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 2/24/20 after presenting for evaluation of lightheadedness, resulting in a fall at home. On admit, WBC was in the 20's and imaging revealed a left superior and inferior pubic ramus fracture. X-rays of the chest revealed pleural effusions. The enrollee is now afebrile and non-toxic. She did not hit her head during the fall and is able to make needs known. The enrollee is now able to function with moderate assistance overall. 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/skin care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly moderate assist for functional transfers and activities of daily living and a lessintensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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: 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 LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient care and does not require transfer to the LTACH.
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 member is receiving medically necessary acute and/or critical care. The member does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, and prophylaxis provided on December 20, 2019.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewings, and prophylaxis. You say that you have these same services done every year by the same dentist. The Plan denied your request. The Plan says the rendering provider does not participate in the Plan's network of providers.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, and prophylaxis provided on December 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 apply the 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 you do not require skilled nursing or therapy services on a daily basis. You do 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crowns and core buildups for teeth #5 and 6.
You asked the Plan to pre-approve the dental services. You say that you are in pain and can barely eat. The Plan denied your request. The Plan says the services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental crowns and core buildups for teeth #5 and 6.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 27, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered to the enrollee on June 27,
2019.
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 you feel that you need the continued care under inpatient rehab admission and acute care therapy is not intensive enough for what the enrollee needs.The Plan denied your request. The Plan says the enrollee can safely receive the services needed in another setting such as a skilled nursing facility, home with home health and physical therapy or home with outpatient therapy.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 does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, he has limited short-term therapy goals of being able to transfer using a sliding board to his wheelchair without hands-on assistance. The enrollee is limited by pain and would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. The enrollee's care can be appropriately provided at an SNF 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 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: 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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically 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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted to acute care on 1/22/2020 with chest pain and found to have MRSA bacteremia with a
sternal abscess and bilateral pulmonary emboli. She has had multiple surgical procedures for the abscess and
now has a wound vac. She is being treated with 6 weeks of intravenous vancomycin and she has finished 4
weeks of oral rifampin. She also is now on Cefepime for Pseudomonas and Enterococcus that grew from her JP
drain. She is on intravenous heparin for the pulmonary emboli with plans to transition to Eliquis. She is getting
total parenteral nutrition through a PICC line and she has a stage IV sacral wound. She is paraplegic and
rehabilitation with physical and occupational therapy are required.
Based on the provided medical records the acute care hospital is able to provide all of the services the enrollee
requires. Based on the provided medical records the enrollee is receiving necessary services and is at an
appropriate level of care in the acute care hospital. Based on the provided medical records the enrollee is
getting these services in the present acute care hospital. Continued care at this level is appropriate until the
enrollee is stable to transfer to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Partially Favorable

You asked the Planto waive the copayments fora colonoscopy. You say thatthis was a screening and should not have a copayment.The Plan saysthatthe outpatient surgery copayment and specialist copayment 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 a $175 copayment for outpatientsurgery.You asked the Plan to waive the copayments for the colonoscopy. The medical records show that this was done for diagnostic (and not screening) purposes. The outpatientsurgery copayment applied correctly. However, we do not see in the outpatient surgery section of the EOC that a separate specialist copayment should apply for the same procedure. The EOC does not properly disclose this cost-sharing intended by the Plan. Therefore, we decided that the Plandoes not have to waive the copaymentforthe $175charge for outpatient surgery.We also decided that the Plan must waive the $35 specialist charge being applied to the colonoscopy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an acute IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an acute IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessaryas 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 careis not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He is currently in an outpatient setting and does not require any acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, his current functionalstatus is not adequately documented.Therefore, it cannot be determined ifthe memberrequires, or would be able to participate in or benefit from anacute rehabilitation therapy program in an IRF. Based on the information provided, the member's care can be appropriately provided at a skilled nursing facility 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveelectroretinography (ERG) with interpretation and report (0509T).You asked the Plan to pre-approveelectroretinography (ERG) with interpretation and report (0509T). You say that the requested ERG is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested ERG.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve electroretinography (ERG) with interpretation and report (0509T). Our reviewer says that the enrollee does not meet Medicare criteria for the requested ERG. Our physician reviewer found the enrollee was seen on 7/3/19 for diabetic eye evaluation. The enrollee did not note any changes in vision and was unaware of recent blood sugar or HgbA1C numbers. VA with correction was 20/25 and 20/20. IOP was elevated to mid-twenties in both eyes. Pupils, EOM and CVF were within normal limits. Anterior segment exam showed corneal scars and cataracts in both eyes. Dilated exam showed C:D ratio 0.5 in both eyes and early age-related macular degeneration (ARMD) changes in the maculae of both eyes. Because of elevated IOP, the enrollee was scheduled for optos, OCT nerve and pachymetry and also started on Travatan Z in both eyes at night and was asked to return in 3 weeks for an IOP check. Images from AS-OCT and macular cube OCT are included from visit date. Return visit on 7/24/19 showed stable VA and IOP in low teens in both eyes after receiving treatment with Travatan Z. The enrollee was to continue drops and was scheduled for VEP/ERG, VF, and OCT ON in 6 months. The issue at hand is whether the enrollee has a covered indication per the LCD criteria for the requested ERG. Based on the notes, the enrollee has been diagnosed with ocular hypertension/glaucoma suspect and does not have a covered indication for ERG. Per LCD criteria and current guidelines, the use of ERG forglaucoma (either diagnosis or management) is considered experimental and investigational as the available published clinical evidence does not support clinical value. Therefore, the use of ERG for glaucoma is non-covered and will be denied as not reasonable and 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 electroretinography (ERG) with interpretation and report (0509T) have not been met.Therefore, we decided that the Plan does not have to pre-approveelectroretinography (ERG) with interpretation and report (0509T).
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 requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/14/20 from her skilled nursing facility post cardiac arrest due to tracheal tube occlusion. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support, ventilator support with tracheostomy care and oxygen supplementation, surveillance laboratory studies, tube feedings, intravenous antibiotics, and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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.