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

We decided that the Plan does not have to pre-approvethe oxygen equipment to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. The Plan denied your request. The Plan says there are in-network options 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 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approvethe oxygen equipment to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Butamben-Tetracaine-Benzocaine spray provided on November 7, 2019.You asked the Plan to pay forthis drug. The Plandenied your request. The Plan says that self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Butamben-Tetracaine-Benzocaine spray provided on November 7, 2019.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 22, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve36 additional routine transportation trips with a stretcher van.You asked the Planto pre-approvethe services. You say that this is medically necessary, as there is no alternate way to get to the dialysis treatments.The Plandenied your request. The Plansaysthis is not covered on top of the existing benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. Transportation by a stretcher van is not a covered benefit. However, the plan does have a benefit for 24 one-way non-emergent transportation trips.Therefore, we decided that the Plandoes not haveto pre-approve36 additional routine transportation trips with a stretcher van.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan has to pre-approveAranesp for the enrollee.You asked the Plan to pre-approvethese services. You saythat you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that Aranesp is covered for specific indications.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 services are medically necessary. Our physician reviewer found the enrollee has myelodysplastic syndrome and anemia. Her hemoglobin level meets the criteria for coverage of Aranesp. The records support that Aranesp is reasonable and medically necessary for 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 these services have been met.Therefore, we decided that the Plan has to pre-approveAranesp for the enrollee.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/orsend 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued SNF services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee is not independent enough to go home.The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNFwhen the four factors listed above are met. Custodial care is not covered.Skilled services beyond March 20, 2020 was 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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a standby assist level with functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursingfacility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmic biometry provided on November 21, 2019.You asked the Plan to waive the copayment forophthalmic biometry. You say that you were told that you would not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests. You have been asked to pay a $20 copayment for ophthalmic biometry. Ophthalmic biometry falls within the outpatient diagnostic tests and therapeutic services and 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 copayment forophthalmic biometry provided on November 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRituximab infusion for the enrollee.You asked the Planto pre-approvethe infusion. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee's diagnosis is not supported by the FDA of CMS compendia.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the infusion. Our reviewer says that the requested infusion is not medically reasonable or necessary. Our physician reviewer found a review of the guidelines and compendia do not support the use of Rituximab for the enrollee's diagnosis. Without the support of the documentation, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe infusion have not been met.Therefore, we decided that the Plandoes not haveto pre-approveRituximab infusion for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you have a broken ankle and other rehab issues.The Plan denied your request. The Plan says the services are not medically necessary.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 requestto pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you had surgery to correct a right ankle fracture on March 13, 2020 and are now not able to bear weight on your right leg. You are medically stable as of March 16, 2020. You have no post-operative complications. You are medically stable with no evidence of need for supervision by an acute inpatient physician or acute rehab nursing care. You may benefit from further therapy but do not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEpiFix allograft skin substitute.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary due to an infection of a bone underneath the wound.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 theservices. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a presence of osteomyelitis, and that needs to be treated first.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEpiFix allograft skin substitute.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no mention of x-ray results or diagnosis of osteoarthritis found in the clinical information.

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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed records do not include imaging study results or discussion of thee months conservative therapy. Without the support of the documentation, this cannot be considered medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is receiving appropriate inpatient acute care anddoes not require transfer to the LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for thediagnosis 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 does not meet the criteria, as he is not on a ventilator. There are no complex wound or specialized nursing 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 Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the admission is not medically necessary.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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with bradycardia and shock. She was admitted to the SNF from March 16, 2020 to March 23, 2020 without authorization. She has noskilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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 requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
You asked the Plan to pre-approve the echocardiogram. You say that this is medically necessary. The Plan denied your request. The Plan says there are no findings that would warrant an approval of this test.
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 echocardiogram. Our reviewer says that the requested transthoracic echocardiogram is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has concern for memory change but no documentation of a focal neurologic event, no history of heart disease, no documented cardiac symptoms, no documented cardiac physical exam abnormalities and no electrocardiographic abnormalities. In this circumstance, the documentation does not support the medical necessity for an echocardiogram. Memory disturbance alone is not a covered indication for the procedure. Coverage criteria are not met since there are no documented covered indications for the procedure.
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 echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the implantable mesh. We decided that the Plan does not have to waive the coinsurance for the unclassified drugs.
You asked the Plan to waive the coinsurance for the implantable mesh and unclassified drugs. You say that you were advised there would be a $300 copayment and everything else would be covered. You say that you were not advised of anything that may not be covered. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to waive the coinsurance for the implantable mesh.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for surgical supplies. The Plan contract does not clearly say how much enrollees must pay for surgical supplies. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the implantable mesh.
We also decided that the Plan does not have to waive the coinsurance for the unclassified drugs.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B chemotherapy drugs and other Medicare Part B drugs. The allowed amount of the unclassified drugs is $99.84 (20% x $99.84 = $19.97). Therefore, we decided that the Plan does not have to waive the coinsurance for the unclassified drugs.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection (J0897) provided on October 14, 2019.
You asked the Plan to waive the coinsurance for a Prolia injection. You say that this should be paid in full. The Plan denied your request. The Plan says this processed 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $190.57coinsurance for a Prolia injection ($952.83 allowed amount x 20% = $190.57). 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 a Prolia injection (J0897) provided on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80307 and HCPCS G0483 remain not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 pay for drug testing services provided to the enrollee on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 2, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. We find that payment for the lab services are not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the tests be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 2, 2019.