Persius/hicric huggingface dataset:
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 you would like the plan to reconsider
their denial The Plan denied your request. The Plan says the requested admission 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 LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee presented to the acute hospital with gram negative sepsis due to an
infected peritoneal dialysis catheter. The enrollee was treated in hospital with multiple intravenous antibiotics
with consultations from infectious disease, general surgery, wound care and nephrology. The documentation
does not support that the enrollee requires services at the LTACH that are not available at the health care
setting being offered by the health plan. Continued care at the acute care hospital level is appropriate until the
enrollee is stable to transfer to a lower level of care. Therefore, the enrollee does not meet criteria for the
requested LTACH 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam.
You asked the Plan to pre-approve Temazepam. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this is not a Part B covered drug.
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 Temazepam.
Benefits for Temazepam 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 9, 2019 to December 4, 2019.You asked the Plan to waive the copayment for the SNF stay. You say that you should not be responsible for the copayment 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 a $0 copayment per day for days 1-20 and a $160 copayment per day for days 21-100 for in-network Medicare-covered services for each benefit period. You have been asked to pay a total of $800 for the SNF stay. The SNF stay falls within "Skilled nursing facility (SNF) care" benefit category. You have been asked pay a $0 copayment for days 1-20 of your SNF stay. You have also been asked to pay an $800 copayment for days 21-25 of the SNF stay. ($160 x 5 = $800).This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay provided by from November 9, 2019 to December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clopidogrel Tablets for the enrollee.
You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this drug
should be covered for the enrollee. The Plan denied your request. The Plan says this drug is not covered under
Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Clopidogrel Tablets for the
enrollee.
Benefits for self-administered drugs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pacemaker insertion provided on January 7, 2020.
You asked the Plan to waive the coinsurance for the pacemaker insertion. You say that if you knew the procedure would be processed a different way, you would have done this different. You say that you should only pay the outpatient coinsurance. 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% coinsurance for surgery services at an in-network outpatient hospital. You have been asked to pay $4,082.73, which is 20% of the allowed amount for the pacemaker insertion. The allowed amount is $20,413.67 (20% x $20,413.67 = $4,082.73). The pacemaker insertion falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the claim was processed as an outpatient procedure. 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 pacemaker insertion provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveInjectafer.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis does not meet the criteria requirements of medical necessity.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the Injectafer infusion at issue in this case is not medically reasonable and necessary as there is currently no evidence of iron deficiency anemia.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveInjectafer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza for the enrollee. You asked the Plan to pre-approve Victoza under Medicare Part B. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B. 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 Victoza for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet joint injections.You asked the Plan to pre-approvethe facet joint injections. You say that the requested injection services are badly needed and urgent in nature.The Plan denied your request. The Plan says the records do not support that the enrollee has pain localizedto either the neck or back, and that does not travel to other areas of the enrollee's body.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 facet joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records document at the enrollee does not satisfy all of the requirements for coverage of facet injections. The medical records document that the enrollee's pain is associated with radiculopathy. 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 facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you believe you will benefit from admission to an
IRF vs. SNF care in order to heal and have a normal lifestyle. The Plan denied your request. The Plan says your
condition is stable and there is no ongoing treatment of acute or chronic medical conditions. You do not meet
medical necessity criteria for admission to an IRF.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You do require skilled physical therapy and occupational therapy but based on the medical
records provided you do not require treatment in an intensive rehabilitation therapy program. Based on the
medical records provided there is concern that you would not be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled
nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve the IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
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 additional physical 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 enrollee has low back pain. The enrollee has
reported pain as high as 10/10. The documentation does not support that the enrollee requires the unique skills
of a professional therapist are required to safely and effectively provide treatment, that the services can be
safely and effectively performed only by a therapist. The documentation does not support that prior physical
therapy has served to provide sustained, significant improvement in pain and/or function and there is no
indication residual deficits could not be addressed via a home exercise program. Therefore, the enrollee does
not meet criteria for the requested 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 additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has bilateral primary osteoarthritis of knee. The documentation does not support
any previous drug trials. The documentation does not support that the enrollee has tried Synvisc, Durolane, or
Gelsyn-3. The documentation does not support that these drugs would not be as effective for the enrollee or
have adverse effects.
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 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for
the enrollee.
You asked the Plan to pre-approve the requested CGM. You say that a CGM is medically necessary for the
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met as the enrollee is
not currently treated with insulin as is required by the coverage criteria.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for a CGM. Based on the medical
records provided, the enrollee does not meet those criteria. Therefore, we decided that the Plan does not have to
pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
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 enrollee was already supposed to be in rehab. You say that IRF care is needed so the enrollee can start the healing process and become mobile.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already walking more than 100 feet. The enrollee's care needs can be met 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician services and testing rendered
on January 16, 2020.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $185 yearly deductible for your covered medical services.
The item or service you asked the Plan to waive the deductible for falls within the specialist services benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $185 yearly
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been
met at the time these services were received on January 16, 2020. Therefore, we decided that the Plan does not
have to waive the deductible for the physician services and testing rendered on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis, knee orthosis and sleeve provided to the enrollee on January 30, 2020.You asked the Plan to pay for these items. The Plan denied your request. The Plan says that they were unable to discover any evidence of an established relationship between the member and the ordering physician.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 the lumbar sacral orthosis, knee orthosis and sleeve provided to the enrollee on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection provided on November 21,
2019.
You asked the Plan to waive the coinsurance for the injection. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received a Part B injection on the date of service at issue in this appeal. The
Plan says that the correct coinsurance has applied per your contract with the Plan.
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 Medicare Part B prescription drugs.
We looked at the file, the Plan's contract and Medicare rules. The file shows you received an injection on
November 21, 2019. You have been asked to pay a 20% coinsurance for the injection, totaling $401.76. The
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 injection provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skin barrier powder and ostomy pouch provided on January 21, 2020 and February 21, 2020.
You asked the Plan to waive the coinsurance for the skin barrier powder and ostomy pouch. You say that you've been getting supplies for 13 years and have never paid a copayment. You say that this should be covered. 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% coinsurance for prosthetic devices and medical supplies. You have been asked to pay a total of $77.64 for the skin barrier powder and ostomy pouch.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
January 21, 2020
Skin Barrier Powder
$4.23
20%
$0.84
January 21, 2020
Ostomy Pouch
$192
20%
$38.40
February 21, 2020
Ostomy Pouch
$192
20%
$38.40
TOTAL:
$77.64
The skin barrier powder and ostomy pouch fall within the "Prosthetic device sand related supplies" 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 skin barrier powder and ostomy pouch provided on January 21, 2020 and February 21, 2020.