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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.

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 that the enrollee was admitted to the current acute care hospital postoperatively, status post a T3-4 kyphectomy and a C2-T10 revision fusion for T4 paraplegia due to sepsis, a urinary tract infection, pulmonary nodular amyloidosis, and respiratory failure requiring intubation, antibiotics, and later trach and percutaneous endoscopic gastrostomy placement. Antibiotics have since been completed, however, weaning attempts have been unsuccessful as the patient's status is unstable and blood pressures are quite variable and often low. Physical therapy was initiated.

It appears that the patient is unstable and should only require short term additional acute care services to further stabilize the patient which can safely be received at the current facility until completed. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has been completed.

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 Aranesp 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 step therapy guidelines were not followed. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical 
records provided the enrollee has not tried and failed the required drug. There is no indication that Retacrit 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that these are the only dental x-rays you have had in three years, and you believe you should be reimbursed. The Plan denied your request. The Plan says you have exceeded the dental allowance and are not entitled to any additional reimbursement.

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 Plan offers an allowance of $1,000 every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract clearly states that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that the enrollee has significant pain. The Plan denied your request. The Plan says the enrollee needs to fail a standard wheelchair before having a specialized type of wheelchair.

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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee has a mobility limitation that significantly impairs the ability to complete MRADLs in the home or that any mobility deficit is unable to be resolved by a cane or walker. The documentation does not reveal an assessment indicating the enrollee's home is appropriate for a wheelchair or that it will significantly improve the enrollee's ability to participate in MRADLs in the home. There is no evidence that the enrollee is unable to propel a standard wheelchair and requires a lightweight wheelchair.

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the service provided was medically necessary. The Plan denied your request. The Plan says there is no evidence that the provider ever had an exam with the enrollee

The Plan follows Medicare rules. Medicare rules say that for a spinal orthosis to be covered, the enrollee must meet Medicare-certified criteria.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer says that the lumbar-sacral orthosis was not medically necessary and reasonable. 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 the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care to be rendered by an out-of-network (OON) provider.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care with the out-of-network provider is medically necessary. The Plan denied your request. The Plan says the record does not show that you have an emergent or urgent medical condition, or are in need of a specialized service. There are several in-network skilled nursing facilities within a reasonable distance from your location that can provide care. The request for an exception is not medically necessary.

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 provider at issue in this case is not a network provider with the Plan. 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 your request for inpatient skilled nursing facility care with the out-of-network provider is not medically necessary. Our physician reviewer found that there is no evidence that the out-of-network skilled nursing facility has specialized services that are not available in network. There is no evidence that the out-of-network skilled nursing facility is needed for an emergency, urgently needed care, dialysis, or that services are not provided within a reasonable distance. You do not have skilled nursing needs such as complex wound care that require the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. While you would benefit from skilled therapy services in a skilled nursing facility on a daily basis, the documentation does not support that your therapy needs require an out-of-network skilled nursing facility over an in-network skilled nursing facility.

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.

The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve SNF care. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care to be rendered by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the physician's office visit. We decided that the Plan does not have to 
pay for the laboratory services.  
 
You asked the Plan to pay for the physician's office visit and laboratory services. You say that you would like 
the Plan to reconsider your request. The Plan says that the cost sharing applied correctly for the office visit 
services and there was no prior authorization for the laboratory services received. 
  
We decided that the Plan has to pay for the physician's office visit.  
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members 
the benefits offered under the plan including applicable conditions and limitations, premiums and cost sharing 
such as copayments, deductibles and coinsurance.  
 
We looked at the file, the Plans contract and Medicare rules. The file shows that you received office visit 
services provided by a general practitioner on October 27, 2020. The Plans contract says a general practitioner 
is considered a primary care provider. The Plans contract says that primary care provider office visits have a 
$0 copayment. Therefore, we decided that the Plan has to pay for the physician's office visit.  
 
We also decided that the Plan does not have to pay for the laboratory services. 
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members 
the benefits offered under the plan including applicable conditions and limitations.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory 
services in a physician's office on October 29, 2020. The file does not show that prior authorization was made 
for these services. The Plan's contract clearly states that laboratory services conducted in a physician's office is 
not covered unless it is authorized by the Plan. Therefore, we decided that the Plan does not have to pay for the 
laboratory services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
October 1, 2020, to October 6, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the services provided to the enrollee are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee received skilled 
therapy until September 30, 2020. The Plan also says that after this the enrollee's condition deteriorated and 
ongoing therapy was not possible. 
 
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 pay for the SNF services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from October 1, 2020, to October 6, 
2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care.

You asked the Plan to pay for the subsequent hospital care. You say that you do not understand why the payment was recouped. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care.
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 that the patient was admitted to the current acute care hospital with altered mentation 
and shortness of breath related to COVID-19, sepsis, and chronic obstructive pulmonary disease exacerbation. 
Lung infiltrates were found on x-ray. She required total parental nutrition, blood transfusion, antibiotics, 
steroids, and physical/speech therapy. She required bilevel positive airway pressure (BIPAP) therapy; however, 
she currently still has leukocytosis and anemia requiring additional treatment and weaning.  
 
It appears that the patient is more stable and is gradually improving and may only require short term additional 
acute care services which can safely be received at the current facility until completed. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Therefore, 
this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower 
level of care may be considered soon when treatment has been completed. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays (71045) provided by a student from April 30, 2020, to 
May 1, 2020. 
 
You asked the Plan to pay for x-rays. You say that these services were provided by a student who is authorized 
to perform services in your group. The Plan denied your request. The Plan says services provided by students 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for any service furnished 
by a student. 
 
We looked at the file and Medicare rules. The record shows that the services at issue were performed by a 
student. Based on this information, we decided that Medicare rules for coverage of x-rays have not been met. 
Therefore, we decided that the Plan does not have to pay for x-rays (71045) provided by a student from April 
30, 2020, to May 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay.

You asked the Plan to waive the copayment for the SNF stay. You say that you were careful to select an in-network provider and you cannot afford the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claims.

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 $160 copayment for skilled nursing facility care.

You have been asked to pay a $3,096.00 copayment ($0 for days 1 - 20, $160 for each day, days 21 - 51, and $0 for additional Medicare covered days, up to day 100) for the SNF stay. You reached your annual maximum out-of-pocket of $4,900 during this SNF stay. This stay falls within the skilled nursing facility care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and evaluation (92014) provided by an out of network (OON) provider.

You asked the Plan to pay for the eye exam and evaluation. You say that this service was rendered in a nursing home setting and there is no way to obtain prior authorization when the provider does not know what patient they will examine. The referral of the nursing home for the services should be authorization enough. The Plan denied your request. The Plan says they do not cover services provided out of network, except in limited circumstances. Prior authorization was not obtained, and the services were not emergent. This situation also would not fall under plan-directed care as the primary services provided at this facility are also considered custodial and are not covered by Medicare. The facility is also not within the Plan's network.

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 eye exam and evaluation (92014) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physician services provided on October 28, 2020. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan is denying payment for services provided on October 28, 
2020, because a different provider was paid for this service provided on May 26, 2020. However, the Plan has 
not provided any documentation showing that these services have already been paid to another provider. The 
Plan has not shown that you have exhausted this benefit. Therefore, we decided that the Plan has to pay for the 
physician services provided on October 28, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.