Persius/hicric huggingface dataset:
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the requested service was medically necessary. The Plan denied your request. The Plan says criteria for obtaining out of network coverage was not 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 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 had network providers available who could have provided 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 office visit provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and dental extractions to be performed by an oral surgeon.

You asked the Plan to pre-approve a consultation and dental extractions to be performed by an oral surgeon. You say that the service is medically necessary. The Plan denied your request. The Plan says the supplemental Dental Services benefit of your contract only provides coverage for dental services when they are performed by a participating general dentist; dental services performed by an oral surgeon are not covered.

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 among those covered under this benefit. Specifically, services must be obtained from a participating general dentist and not an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a consultation and dental extractions to be performed by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Mammography services (77063, 77067).

You asked the Plan to pay for the Mammography services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was a duplicate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 77063, & 77067 are not supported in the medical record. Specifically, the record only supports 1 unit each for these CPT codes. The plan has already paid for 1 unit each of these services on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the Mammography services have not been met. Therefore, we decided that the Plan does not have to pay for Mammography services (77063, 77067).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, G2023).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says these services are not covered when performed at an ambulatory surgical
center (ASC).

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT codes 80053, & G2023 are not supported in the medical record. Specifically, neither service
appears on Medicare's 2020 list of Ambulatory Surgical Center (ASC) Approved HCPCS Codes and Payment
rates. Based on this information, we decided that Medicare rules for coverage of the lab services have not been
met. Therefore, we decided that the Plan does not have to pay for lab services (80053, G2023).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the determination of a refractive state (99215).

You asked the Plan to pay for the determination of a refractive state. You say that you would like
reconsideration because you were told this service would be covered if you went to an ophthalmologist. The
Plan denied your request. The Plan says that this service is not covered by Medicare.

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. Specifically, you state in your appeal that you were told by the Plan that this
service would be covered if it were rendered by an Ophthalmologist. The record shows that the Plan has
acknowledged this phone call but has not provided a transcript or evidence that you were given incorrect
information. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is
not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pay for the
determination of a refractive state (99215).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet injections.

You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this treatment is clinically supported and medically necessary. The Plan denied your request. The Plan says the first diagnostic block did not yield 80% pain relief.

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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the presence of radiculopathy and failure of the first set of MBBs to achieve over 80% pain relief does not meet the criteria for 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health therapy provided by a participating provider.

You asked the Plan to waive the copayment for outpatient mental health therapy. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient mental health care.

The enrollee has been asked to pay a $40 copayment for each outpatient mental health therapy session. The total amount you are being asked to pay is $240 ($40 x 6 sessions = $240). Outpatient mental health therapy falls within the outpatient mental health care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient mental health therapy provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram (77063, 77067) provided by an OON provider.

You asked the Plan to pay for the mammogram. You say that the Plan should cover the service. The Plan
denied your request. The Plan says out-of-network criteria were not met for the requested service.

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 had network providers
available who could have provided 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 mammogram (77063, 77067) provided 
by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient back surgery (kyphoplasty) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not necessary based on the clinical documentation.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the fracture is greater than 6 weeks old. Also recent literature has shown that kyphoplasty is not more effective than sham therapy for compression fractures. It is not medically needed 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient back surgery (kyphoplasty) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this copayment is too
high. You say that you cannot afford this because you have a lot of other bills. The Plan denied your request.
The Plan says the correct copayment has been applied.

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 $360
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.

You have been asked to pay a $360 copayment per day for days 1-2 for an inpatient hospital stay. The total
amount you are being asked to pay is $720 ($360 x 2 days = $720). An inpatient hospital stay falls within the
inpatient hospital care/in-network 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 inpatient hospital stay provided by a participating provider

We note you would like to work out a financial deal with the Plan. Your complaint is a grievance that must be
answered by the health 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 CT scan of the head or brain for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says no coverage for this treatment can be approved.

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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found Medicare regulations say that a CT scan may be covered when it is reasonable and necessary. In this case the enrollee presented to her primary care provider with non-specific complaints. The enrollee had a normal neurological examination at the time of her visit. She had no findings on her exam to suggest the presence of any form of intracranial process. Her provider otherwise had noted that her complaints were "vague". In as much a presentation, it cannot be determined that a CT of the head at this time would be considered to be reasonable and necessary for evaluation of this type of clinical presentation. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the head or brain for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant (D6010) provided on August 26, 2020.

You asked the Plan to pay for the endosteal implant. You say that you were told that you had dental coverage. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endosteal implant (D6010) provided on August 26, 2020.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 27, 2021 after being found unresponsive in a skilled nursing facility. He was in no acute distress on March 10, 2021 and had a tracheostomy in place. 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-approve long term acute care hospital (LTACH) 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 it would be beneficial for care to be provided in the LTACH setting. The Plan denied your request. The Plan says there is no medical need for transfer to an 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) and paclitaxel treatment
regimen.

You asked the Plan to pre-approve the Keytruda and paclitaxel regimen. You say that it is felt that this should
be tried as it would be helpful. The Plan denied your request. The Plan says there is not sufficient support for
this treatment.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Keytruda and paclitaxel regimen.
Our reviewer says that the requested treatment regimen is not considered medically reasonable and necessary in
this case. Our physician reviewer found the enrollee is a male with Lynch syndrome who was treated with
gemcitabine/carboplatin with Keytruda for metastatic bladder cancer. There was a recent finding of liver
metastasis of the bladder cancer. The plan is to provide another course of Keytruda with a taxane, such as
paclitaxel.

Keytruda with a taxane is not FDA-approved for the enrollee's condition, and Keytruda alone is not FDAapproved
with progression after prior use of the treatment. The requested regimen is not supported by the major
drug compendia or Medicare-approved journals.

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 Keytruda and paclitaxel regimen have not been met. Therefore, we decided
that the Plan does not have to pre-approve Keytruda (pembrolizumab) and paclitaxel treatment regimen.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the requested procedure is not indicated at this time.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The imaging studies do not show any evidence of spinal instability or severe stenosis. The MRI does not show severe pinching of neurologic structures. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve spine surgery for the enrollee.