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

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the member does not meet the steptherapy exception 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 Prolia. Our reviewer says that the member has not tried and failed a trial of zoledronic acid. Our physician reviewer found the Plan's required drugs would not likely be less effective and/or likely 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve continued services. You say that rehab can make a positive difference in the enrollee's overall health. The Plan denied your request. The Plan says the enrollee has no other skilled needs, but significant long term care needs.
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. Continued SNF services beyond February 10, 2020 were requested for 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 continued services. Our physician reviewer found that recovery from his recent injury is hindered by dementia as well as other chronic medical conditions including high blood pressure, coronary artery disease, arthritis, prostate cancer, anemia, and diabetes, dementia, peptic ulcer. The medical records indicate that prior to his hospitalization, he was needing assistance with dressing, bathing, grooming, and transfers, and had not been ambulating for the three months prior. As of February 10, 2020, the enrollee had achieved his highest practical level. He was max assist for upper and lower body bathing, dressing, oral hygiene, toilet hygiene. The enrollee does not require skilled nursing or therapy services with the specialized skill, knowledge and judgment of a skilled professional to safely and effectively provide treatment. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond February 10, 2020.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and chiropractic manipulative treatment of extraspinal regions received from July 29, 2019 to August 20, 2019.
You asked the Plan to pay for the office visits and chiropractic manipulative treatment of extraspinal regions. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visits and chiropractic manipulative treatment of extraspinal regions received from July 29, 2019 to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on July 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 96413 and 96417 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. The definition of code 96417 is chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure). We find that CPT codes 96413 and 96417 are not supported in the medical record. Specifically, the documentation does not contain record of the time over which the infusion was administered; therefore, code 96413 is not supported. Code 96417 is an add-on code to 96413 and is therefore also not supported. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen provided from August 1, 2019
through October 1, 2019.
You asked the Plan to waive the coinsurance for the oxygen. The Plan denied your request. The Plan says that
you are responsible for a 20% coinsurance.
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 Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for the oxygen. The oxygen falls within the Durable medical
equipment (DME) and 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 oxygen provided from August 1, 2019 through October 1, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department (ED) services rendered to you on September 6, 2019.
You asked the Plan to waive the copayment for these services. You say that you are dissatisfied with the services. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for emergency care.
Review of the file shows that you received ED services on September 6, 2019. You have been asked to pay a $100 copayment for these services. These services fall within the emergency 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 emergency department (ED) services rendered to you on September 6, 2019.
Your complaint about the hospital 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: Inpatient Hospital
Decision: Unfavorable


 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to a SNF on 11/15/19 after a mitral valve replacement with complications of cerebral vascular accident (CVA), cardiac arrest, and respiratory failure. She was tracheostomy and vent dependent in the SNF. She has a history of a left atrial appendage ligation. She was independent with self-care and activities of daily living with walker and cane. Lives on first floor of 2 story home with daughter and granddaughter. On 11/17/19 she was dependent in all activities of daily living in physical therapy (PT). On 11/18/19 in occupational therapy (OT) she was unable to move upper extremity to assist with rolling which is dependent. She is dependent for bed mobility. She is dependent for activities of daily living. She has impaired cognition and eyes open on and off during sessions. On 1/27/20 in PT she is partial/moderate assist for rolling, partial/moderate assist for sit to lying; partial/moderate assist for lying to sitting on one side of the bed. She is dependent for dressing and putting on/off footwear. On 1/27/20 she was decannulated and on 2 L oxygen. She was getting osmolyte through g-tube and getting pureed diet/thin liquid. On 1/28/20 she was minimal assist with bed mobility, maximum/dependent for transfers and did not ambulate in PT. On 1/28/20 in OT she was dependent for self feeding and moderate/dependent for activities of daily living. 
 
The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from additional therapy of PT and OT but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF. 
 
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 pay for a domiciliary or rest home visit provided on October 11, 2019. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 23, 2019. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were under the impression that all cleanings were covered. You say that your policy did not make that clear. The Plan denied your request. The Plan says periodontal scaling and root planing is not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Progensa PCA-3 testing to be provided in order to (potentially) avoid prostate biopsy.
You asked the Plan to pre-approve the Progensa PCA-3. You say that it is known that there are higher risks for a biopsy procedure for those who are over the age of 70. You believe that you should be allowed this testing which could show a lower risk so you could avoid having the biopsy. The Plan denied your request. The Plan says this is only covered for men who have had a prior negative prostate biopsy. In your case, an initial biopsy is indicated to determine the presence of cancer and this testing is not an appropriate substitute.
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 Progensa PCA-3. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the PROGENSA PCA3 assay is indicated for use in conjunction with other patient information to aid in the decision for repeat biopsy in men 50 years of age or older who have had one or more previous negative prostate biopsies and for whom a repeat biopsy would be recommended by a urologist. The medical records provided indicate that this patient has not had a prostate biopsy. Also, the results of a 4K Score was 23% indicating high risk for high grade prostate cancer and a biopsy is indicated. As such, PROGENSA PCA3 assay testing would not be reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Progensa PCA-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve the Progensa PCA-3 testing to be provided in order to (potentially) avoid prostate biopsy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on August 28, 2019 by out of network provider.
You asked the Plan to pay for drug testing. You say that you are seeking a review and requesting payment for the claim. The Plan denied your request. The Plan says the provider is a non-network provider who does not work with the member's health plan. The member was referred by a doctor who also does not work with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 has network providers available who can provide 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 drug testing (G0482) provided on August 28, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2019 to August 17, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 26, 2019 to September 8, 2019. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 10, 2019 to August 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 24, 2019 to August 29, 2019 and from September 4, 2019 to September 22, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility level of care. 
 
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 skilled nursing 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 24, 2019 to August 29, 2019 and from September 4, 2019 to September 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing stool analysis for blood (82274) provided on June 14, 2019 by out of network provider.
You asked the Plan to pay for testing stool analysis for blood. You say that your doctor referred you to go to the medical center and you should not be financially responsible. The Plan denied your request. The Plan says the provider is out-of-network. The services were non-emergent and could have been provided within the 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 has network providers available who can provide 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 testing stool analysis for blood (82274) provided on June 14, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 indenying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care from 1/19/20 to 1/21/20 with ST-elevation myocardial infarction (STEMI), angioplasty and stenting. The enrollee discharged to home. From a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs with some low normal blood pressures. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the home setting. The enrollee was at a stand by assist level with functional mobility including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs.  There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF)