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

We decided that the Plan does not have to waive the cost-sharing for diagnostic procedures, radiology tests, imaging contrast agent, and a Medicare Part B prescription drug injection.

You asked the Plan to waive the cost-sharing for diagnostic tests, imaging supplies, and injection. You say that you are appealing the charges on these claims. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.

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 copayment for each non-radiological test, $150 copayment for each radiological test, 20% coinsurance for imaging supplies, and 20% coinsurance for Part B drug injection. For some of the services, you have been asked to pay the allowed amount of the service if it is less than the applicable cost-sharing amount. A summary of your cost-sharing amounts is shown in the provided table.

Your total cost-sharing responsibility is therefore $550.49.

You have been asked to pay $20 copayment or less for each non-radiological test, $150 copayment for each radiological test, 20% coinsurance for imaging supplies, and 20% coinsurance for Part B drug injection. Diagnostic tests, imaging supplies, and injection fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Medicare Part B Prescription Drugs" benefit categories. 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 cost-sharing for diagnostic procedures, radiology tests, imaging contrast agent, and a Medicare Part B prescription drug injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office services. You say that you have been seeing this doctor for a long time to monitor your condition, and you do not want to change. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency ablation of nerves innervating the
sacroiliac joint (64625).

You asked the Plan to pre-approve the radiofrequency ablation of nerves innervating the sacroiliac joint. You
say that this service is medically necessary. The Plan denied your request. The Plan says the requested
procedure is considered experimental and investigational.

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 the radiofrequency ablation of nerves
innervating the sacroiliac joint. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found This service is considered an
experimental/ investigational procedure because of the wide variation in published efficacy. Therefore, the
request is considered not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the radiofrequency ablation of nerves innervating the sacroiliac joint have not
been met. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation of
nerves innervating the sacroiliac joint (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650).

You asked the Plan to pre-approve a lumbar-sacral orthosis. You say that the item is medically necessary. The
Plan denied your request. The Plan says there is insufficient documentation to indicate the medical necessity of
the item provided.

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 a lumbar-sacral orthosis. Our reviewer
says that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found an appropriate history and a physical examination of the back would reasonably be required to
adequately assess whether the coverage criteria for an LSO have been met. The documentation does not
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as
there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Specifically, there is insufficient
documentation of a credible evaluation and a credible physical examination of the back. This means medical
necessity cannot be determined. Therefore, we decided that the Plan does not have to pre-approve a lumbarsacral
orthosis (L0650).
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 service is medically necessary. The Plan denied your request. The Plan says services can be obtained at 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. Our physician reviewer found there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, the services needed can be obtained at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxervate Sol 20mcg/ml for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 Oxervate Sol 20mcg/ml for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reprocess the copayment for the continuous positive airway pressure (CPAP) supplies (A7038, A7046, A7034, A7032, A7035).

You asked the Plan to reprocess the copayment for the CPAP supplies. You say that you were previously charged a smaller amount for these services. The Plan denied your request. The Plan says the copayment has processed correctly for this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for durable medical equipment.

You have been asked to pay a $50 copayment for the CPAP supplies (5 items x $10 copayment). The items provided fall within the durable medical equipment 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 reprocess the copayment for the continuous positive airway pressure (CPAP) supplies (A7038, A7046, A7034, A7032, A7035).

Your complaint about the Plan charging you a greater amount by billing each item separately when they previously billed each item together is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).

You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support this test needs to be repeated.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that based on the medical records provided, there is no documentation that a CT scan of the abdomen and pelvis is medically reasonable and necessary in this case. Our physician reviewer found given the lack of lymphadenopathy in the examination, along with the lack of concerning signs or symptoms, the likelihood of an underlying condition being found on follow-up CT scanning is very low and further clinical monitoring would be consistent with current standard 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 a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).
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 service is medically necessary. The Plan denied your request. The Plan says the enrollee's medical needs can be obtained 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. Our physician reviewer found there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, services can be obtained in a lower level of care. This means that admission to an IRF is not medically necessary or reasonable. 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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says that the information provided does not show that the member had blockage of urine flow, worsening kidney function that did not improve, severely high or severely low blood sodium, or severely elevated blood potassium level.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found given the enrollee's advanced age, multiple medical problems, and significant laboratory abnormalities, the documentation supports that it was reasonable for the admitting physician to expect that this enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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 Vyvanse.

You asked the Plan to pre-approve Vyvanse. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Vyvanse.

Benefits for Vyvanse may 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and panoramic x-
ray provided on October 19, 2020, by an OON provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and panoramic x-ray. You say that you 
were not aware that this provider was OON. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered 
because your healthcare plan does not have OON benefits. 
 
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, you are responsible for 100% of the 
cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation and panoramic x-ray provided on October 19, 2020, by an OON 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130) to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve a total hip arthroplasty to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a total hip arthroplasty (27130) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) scan services. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has Grade 2a follicular lymphoma 
of the lymph nodes of multiple regions and the records provided support the need for the requested PET scan. 
The Plan denied your request. The Plan says that the clinical information provided does not meet the criteria for 
coverage and is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the PET scan. Our reviewer says that 
the requested PET scan is medically necessary. Our physician reviewer found the enrollee has not had 3 
subsequent PET/CT scans. Our physician reviewer found that a subsequent PET/CT for follicular lymphoma is 
appropriate according to medical standards 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve positron emission tomography (PET) scan services.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that they would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his/her functional status. The enrollee is ambulating up to 40 feet with minimal assistance. The enrollee requires ongoing skilled care but can receive care at 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is not able to participate in an intensive therapy program.

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 physician reviewer found that the enrollee was admitted to the acute hospital for atrial fibrillation and a urinary tract infection. His medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.