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

We decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) provided on November 5, 2019.
You asked the Plan to pay for the lumbar sacral orthosis. You say that you would like reconsideration as this DME is medically necessary. The Plan denied your request. The Plan says the member has previously received the same item from the same provider less than 5 years prior. The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar sacral orthosis have not been met. Specifically, the record does not indicate that the DME has been irreparably damaged. This DME was received prior tp tje 5 years which Medicare determines in the reasonable useful lifetime of equipment. Therefore, we decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) provided on November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecervical/thoracic facet injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested procedure is supported if pain is localized to either the neck or back, and does not travel to other areas of the body.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 ound the degree and duration of the prior facet blocks do not meet the LCD criteria. The requested procedure is not 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 Plandoes not haveto pre-approvecervical/thoracic facet injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve a power operated vehicle. You say that you are visually impaired but you can see going down the street. The Plan denied your request. The Plan says the record does not show you can safely operate a power operated vehicle.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you cannot safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Alteplase recombinant injection provided on June 24, 2019.
You asked the Plan to waive the coinsurance for the injection. The Plan denied your request. The Plan says that there is a 20% coinsurance for Medicare Part B prescription 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 a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs 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 Alteplase recombinant injection provided on June 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approv ethe retrograde filling (D3430) and the apicoectomy (D3410).You asked the Plan to pre-approvethe dental services. You say that the enrollee had a root canal 22 years ago. You say that apical surgery is needed to clean out the infection and alleviate the enrollee's pain and throbbing.The Plan denied your request. The Plan says retrograde fillings and apicoectomy are not listed as 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 requested services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe retrograde filling (D3430) and the apicoectomy (D3410).
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-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the LTACH admission is not 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 that the enrolleeis currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis of her foot. Shehas undergone surgical debridement including a first toe amputation. The enrollee continues to receive wound care and a prolonged course of antibiotics. Sheis not intubatedor ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time noacute services are required. Shecan 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.You asked the Plan to pre-approveRetacrit. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Retacrit has been approved for the enrollee under the enrollee's Medicare Part D benefit through December 31, 2020.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveRetacrit.Benefits for Retacritmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection (62321).
You asked the Plan to pre-approve the epidural steroid injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says coverage of an epidural injection for pain for diagnosis of cervical disc disorder with myelopathy is not medically necessary.
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 epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no radicular component of the pain documented and no physical signs documented that support an indication for an epidural steroid injection. 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 epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (62321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 26, 2019.
You asked the Plan to pay for the laboratory services. 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 service 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 laboratory services provided on July 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic ultrasound and a duplex scan provided on July
17, 2019.
You asked the Plan to pay for the diagnostic ultrasound and duplex scan. 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 diagnostic ultrasound and a duplex scan provided on July 17,
2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ultrasound provided on October 14, 2019.
You asked the Plan to reduce the copayment for the ultrasound. You say that you should only be responsible a $20 copayment for a non-radiologic diagnostic service. 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 $100 copayment for each in-network Medicare-covered diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you had a ultrasound that scans blood flow which is considered a diagnostic radiological service.
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 reduce the copayment for the ultrasound provided on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 14, 2019 to October 22, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient level care was medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the services at issue were medically necessary, it was reasonable to expect the enrollee's admission to span more than 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 14, 2019 to October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided October 5, 2019 to October 7, 2019.Youasked the Plan to pay forthe inpatient hospital services. You say that the services at issue were medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital services. Our reviewer says that the enrollee was stable for transfer to anin-network facility. Our physician reviewer found the review indicates that after 10:00a.m. on October 6, 2019 the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for inpatient 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 the inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay forpost-stabilization inpatient hospital care provided October 5, 2019 to October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe back brace provided on October 23, 2019.You asked the Plan to waive the coinsurance forthe brace. You say that you should not have to pay because you didn't use it because of extreme discomfort.The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, 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 brace. The brace 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 forthe back brace provided on October 23, 2019.
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 member needs daily physician monitoring and assessment. The Plan denied your request. The Plan says there is no advantage in transferring the member 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 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 as LTACHs and ACHs are licensed to provide the same level of care, 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 LTC 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are
available in-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 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 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-approve medical
services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the knee replacements provided from
August 26, 2019 through August 28, 2019 and October 14, 2019 through October 15, 2019.
You asked the Plan to waive the cost share for the knee replacements. You say that you were in the hospital
overnight so you were an inpatient. You say that your bill would have been less if you were an inpatient. The
Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for all other services at an in-network outpatient hospital, 20% coinsurance for all other
professional services at an in-network outpatient hospital and a $40 copayment per in-network provider, per
day for outpatient rehabilitation services. You have been asked to pay a total of $5,769.82 for the knee replacements.
The knee replacements fall within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The anesthesia services fall within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The physical therapy falls
within the "Outpatient rehabilitation services" benefit category. The records show that the knee replacements
were an outpatient 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 cost share for the knee replacements provided from August 26, 2019
through August 28, 2019 and October 14, 2019 through October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trigger point injections (20553x3).
You asked the Plan to pre-approve the trigger point injections. You say that the trigger point injections are medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the medical record did not show the location and severity of the trigger points and no conservative treatment has been trialed.
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 trigger point injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has been receiving these injections on a regular basis without sustained improvement. There is no documentation of other conservative therapy recently. 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 trigger point injections have not been met. Therefore, we decided that the Plan does not have to pre-approve trigger point injections (20553x3).