Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepulmonary services to be provided to the enrollee by an out-of-referral circle provider.You asked the Plan to pre-approvethe requested provider. You say that the enrollee does not want to start over with new people.The Plan denied your request. The Plan says the enrollee is able to see a provider within the referral circle.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-referral circle providers only in cases involving emergencies, and care that cannot be provided by referral circle providers.The requested provider in this case is not in the enrollee's referral circle. The Plan has network providers available within the referral circlewho can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvepulmonary services to be provided to the enrollee by an out-of-referral circle provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe sacroiliac joint injection provided on November 5, 2019.You asked the Plan to waive the copayment forthe sacroiliac joint injection. You say that you had a simple injection done in the doctor's office and not in an outpatient hospital setting. You say your copayment is excessive. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $290 copaymentfor surgery services at an outpatient hospital. You have been asked to pay a $290 copayment for the sacroiliac joint injection. The sacroiliac joint injection falls within the "Outpatient hospital services" benefit category. The record shows you were billed by the outpatient hospital. The record also shows the sacroiliac joint injection is considered a surgical procedure.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 forthe sacroiliac joint injection provided on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from September 25, 2019 through October 10, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that there was no break in care. You say that there shouldn't be another copayment.The Plan denied your request. The Plan says the copayment 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 $325 copayment per day, days 1 to 5 and a $0 copayment per day, days 6 to 90 for each in-network inpatient hospital stay. Your contract with the Plan clearly says that your inpatientcost share will begin on day one each time you are admitted or transferred to a specific facility type, including inpatient rehabilitation facilities, long termacute care (LTAC) facilities, inpatient acute care facilities, and inpatientpsychiatric facilities.You have been asked to pay a $1,625 copayment for the inpatient stay. ($325/day x first 5 days = $1,625). The inpatient stay falls within the "Inpatient hospital 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 forthe inpatient stay provided from September 25, 2019 through October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 18, 2019.You asked the Plan to waive the copayment for laboratory services. You say that your doctor ordered home blood draws. You say that it should be covered under home health.The Plan denied your request. The Plan says the copayment 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 $10 copayment for Medicare-covered lab services. You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 for laboratory services provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forpodiatry services provided on October 29, 2019.You asked the Plan to waive the copayment forpodiatry services. You say that you disagree with the charges because you were never charged in the past.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 $45 copayment for podiatry services. You have been asked to pay a $45 copayment for podiatry services. Podiatry services fallwithin the podiatry services 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 forpodiatry services provided on October 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is refusing to participate in skilled 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 pre-approve SNF services. Our physician reviewer found that you had a recent hospitalization for treatment of respiratory failure and Staphococcal bacteremia. Of the records available, it appears your medical conditions are now stable. Physical therapy was attempted, but you flatly refused to work with therapy. No other therapy notes are available for review. You do not require skilled nursing or therapy services to safely and effectively provide medically necessary and reasonable treatment. The provided medical records do not indicate a need for daily skilled services, or a need for inpatient 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapy services by a telehealth provider.You asked the Plan to pre-approve telehealth services. You say that you need to see a deaf counselor because they have an understanding of your situation.The Plan denied your request. The Plan says the plan does not cover home telehealth visits.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service requested will be provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Therefore, we decided that the Plan does not have to pre-approve outpatient therapy services by a telehealth provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission 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 services could be provided in another setting.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 in the case of this enrollee, although it was clear that ongoing oxygen supplementation and physical therapy was needed due to deconditioning, these services could be provided outside of an acute care facility and be productive as intended. There was no other clear acute care needs to support more than 25 days of staying at a long-termacute care facility. There wereno required services proposed at the LTACH which were not already being provided and covered at the current setting or a lower level of care. Therefore, this request for LTACH services will be considered not medically 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox.You asked the Plan to pre-approveBotox. The Plan denied your request. The Plan says that gastroparesis as it is not an approved use.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 Botox. Our reviewer says that Botox is not medically reasonable and necessary in this case. Though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. Our physician reviewer found that your condition does not meet criteria for coverage of Botox.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the PET Scan (78816). You say that you would like reconsideration as you would prefer to see this provider. The Plan denied your request. The Plan says the records submitted do not show medical necessity for a PET Scan to be performed at this hospital.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, outof 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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for  laboratory testing provided  on December 27, 2018.
You asked the Plan to pay for lab test. You say that this testing was ordered by the enrollee's treating physician because it was medically necessary. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because it is uncertain how this testing would improve health outcomes.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not specified whether the ordering physician is in-network or out-of-network with the Plan. The record does not show that prior notice was given that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that their decision to deny payment for this service is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing providedon December 27, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePembrolizumab (Keytruda) for the enrollee.You asked the Plan to pre-approveKeytruda. You say that the enrollee's cancer has progressed on prior lines of chemotherapy.The Plan denied your request. The Plan says the use of the drug is not supported for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our physician reviewer found that the enrollee has metastatic pancreatic cancer. The cancer has PDL-1 90% expression and is microsatellite (MSI) stable. Keytruda is not FDA-approved for MSI-stable pancreatic cancer. The drug is not supported in any of the CMS approved compendia for the requested use. This review did not find any supporting citations in a PubMed search.Therefore, the use is not listed as not indicated, not supported or not recommended in any of the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approvePembrolizumab (Keytruda) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a stairway elevator.You asked the Planto pre-approve the elevator. You say that this is medically necessary.The Plan denied your request. The Plansays elevators are a convenience item, and not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea stairway elevator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 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 a failed trial of zoledronic acid is required prior to coverage of Prolia.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 does not meet the step therapy guidelines. Our physician reviewer found the review has determined that the Plan requires a trial of zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). The plan's required drug is not 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 Prolia for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay from November 27, 2018 to December 3, 2018.You asked the Plan to waive the copayment foran observation stay. You say that you were admitted under observation and disagree with the inpatient charges.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 $225 copayment for outpatient observation services. The medical records show that you had an observation stay from November 27, 2018 to December 23, 2018. Therefore, you are responsible to pay the $225 copayment, which is less than the inpatient hospital copayment. You have been asked to pay a $225 copayment for an observation stay. An observation stay falls within the outpatient hospital services benefit category. This means that you have been askedto 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 foran observation stay from November 27, 2018 to December 3, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76770) provided on November 15, 2019.You asked the Plan to waive the copayment for the ultrasound. You say that you do not understand why you are responsible for a copayment. The Plan denied your request. The Plan says you are responsible for the first $125 for diagnostic testing and based upon claim processing, there were no additional amounts for the Plan to pay.The rules say a plan must disclose to its enrolleesin 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 $125 copayment for outpatient diagnostic tests. You have been asked to pay a $104.61 copayment for the ultrasound. The allowed amount for this service is $104.61. The ultrasound falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound (76770) provided on November 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.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 the complexity of the patient's nursing, medical,and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical and occupational therapy, but the patient 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 rulesfor coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.