Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure (B4150) and Ensure Plus (B4152).
You asked the Plan to pre-approve the Ensure and Ensure Plus. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you are not fed through a feeding tube so this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition products that are administered orally and related supplies are noncovered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Ensure and Ensure Plus have not been met. Specifically, the record indicates that you will use Ensure orally. Oral enteral nutrition products are not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve Ensure (B4150) and Ensure Plus (B4152).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied
your request. The Plan says that they did not receive documentation supporting the medical necessity for a step
therapy exception.
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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically reasonable and necessary for the enrollee in this case. The documentation does
not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less
effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found
that the enrollee's condition does not meet step therapy criteria for Synvisc-One.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90837, 90791) provided from October 1 to October 10, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that you were told the provider was in-network and the services should be covered. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that LPC's are not eligible for enrollment in the Medicare program and cannot receive Medicare payment. We looked at the file and Medicare rules. This provider is not eligible for Medicare reimbursement. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837, 90791) provided from October 1 to October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740) for teeth #8 and 10, and the
porcelain pontic (D6245) for tooth # 9 provided on August 26, 2019.
You asked the Plan to pay for the dental services. You say that one of the crowns you have had for over 30
years came off and needed to be replaced. The Plan denied your request. The Plan says the dental services you
received are not covered services.
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 dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
retainer crowns (D6740) for teeth # 8 and 10, and the porcelain pontic (D6245) for tooth # 9 provided on August 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 27, 2019 to August 25, 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 did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
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 July 27, 2019 to August 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.You asked the Plan to pre-approve these services. You say that you can't walk or bear weight on your knee.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered when specific criteria are met.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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you have right knee pain and osteoarthritis of the knee. There is no documentation of a recent injury or surgical procedure to the knee. There is no demonstrated knee instability documented in an exam or objective description of excessive flexibility of the joint (joint laxity). The requested knee orthosis is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a knee orthosis
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the tomosynthesis. We decided that the Plan does not have to waive the coinsurance for the diagnostic mammogram and tomosynthesis.
You asked the Plan to waive the coinsurance for the diagnostic mammogram and tomosynthesis. You say that your wife is covered for the service. You say that it should be covered for you. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the coinsurance for the tomosynthesis.
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 tomosynthesis is considered a diagnostic test.
The Plan says that you must pay 50% coinsurance for the tomosynthesis. Based on the Plan contract, however, you cannot be asked to pay more than 30% coinsurance for the tomosynthesis. The allowed amount of the tomosynthesis is $30.14 (30% x $30.14 = $9.04). Therefore, we decided that the Plan has to reduce the coinsurance for the tomosynthesis from $15.07 to $9.04.
We also decided that the Plan does not have to waive the coinsurance for the diagnostic mammogram.
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 30% coinsurance for the diagnostic mammogram. Therefore, we decided that the Plan does not have to waive the coinsurance for the diagnostic mammogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including oxygen supplementation, wound care, intravenous antibiotics, surveillance laboratory studies, fluid balance, specialty consultants, and therapy services. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on October 10, 2019 by an out of network provider.
You asked the Plan to pay for the vision services. You say that you weren't able to find an ophthalmologist with appointments available. The Plan denied your request. The Plan says that there were plan providers available.
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 the vision services provided on October 10, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care specialist services provided to the enrollee on July 13, 2019, by an in-network provider.You asked the Plan to waive the copayment for vision care specialist services. You say that the enrollee should not be liable for the cost share due to having to see another provider for a second opinion.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received vision care specialist services provided on July 13, 2019, by an in-network provider. The enrollee is asked to pay a $35 copayment for specialist office services. 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 vision care specialist services provided to the enrollee on July 13, 2019, by an in-network provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the enrollee still needs to be in a SNF. The Plan denied your request. The Plan says that that there was no need for skilled nursing services on a daily basis and the member did not require skilled rehabilitation services daily.
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 pre-approve SNF care. Our reviewer says that SNF services are medically reasonable and necessary for the enrollee in this case. The enrollee is now approximately two months status-post fall with compression and sacral insufficiency fractures. There has been a recent change in her pain management regimen and healing after the fractures would be expected to be occurring. Her pain can be expected to decrease. The member has functionally limiting pain which needs to be assessed and treated. She is at risk for secondary complications of immobility such as pressure ulcers and contractures. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. There is no evidence that she is able to perform essential activities of daily living such as bed mobility without assistance. The member's condition would be expected to deteriorate with services provided on a less than daily basis. The member had previously been able to function independently. With adequate pain control and healing of her fractures there is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care being requested. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 31, 2018.
You asked the Plan to pay for the train of four testing. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says train of four is considered a bundled procedure and payment for it is included in the payment for the already-approved neuromonitoring.
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 code 95999 is not supported in the medical record. Specifically, the record indicates the CPT code 95999 represents train of four testing. Train of four testing is considered a bundled service and included in the payment for the approved neuromonitoring service. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 31, 2018.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and O2 as well as nutritional care, and daily therapy can be provided at a SNF. In this case, the member is mostly MODERATE to MAX assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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: 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 the clinical documentation supports the request for LTACH services. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that they will continue to cover acute level care at the current hospital for as long as it is 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 is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and renal failure. Her hospitalization was complicated by DIC and an intraabdominal hemorrhage. The enrollee has received antibiotics, hemodialysis and transfusions. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 a radiologic examination provided on May 2, 2019.
You asked the Plan to pay for the radiologic examination. The Plan denied your request. The Plan says that the 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 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 radiologic examination provided on May 2, 2019.