Persius/hicric huggingface dataset:
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 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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided through outpatient and home-based physical therapy.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe presumptive drug testing rendered to enrollee on January 9, 2019.You asked the Plan to pay forthese servicess. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 80307 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 80307 is presumptive drug testing, any number of classes.We find that CPT code 80307 is not supported in the medical record. Specifically, there is no lab results for presumptive drug testing. Based on this information, we decided that Medicare rules for coverage of these servicess have not been met.Therefore, we decided that the Plan does not have to pay forthe presumptive drug testing rendered to enrollee on January 9, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 1, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because it was not your decision to go the hospital. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram.You asked the Plan to pre-approve a transthoracic echocardiogram. You say that the service is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that a transthoracic echocardiogram is covered when specific criteria is 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 a transthoracic echocardiogram. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the records the enrollee is a 64-year old woman with transient mild reduction in left ventricle (LV) ejection fraction most recently improved to low normal on an echocardiogram about 1 year ago. There is no documentation to support any new symptoms or clinical change since that echocardiogram about 1 year ago. Therefore, the documentation provided does not support the medical necessity for a repeat echocardiogram 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 a transthoracic echocardiogram have not been met.Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
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 records provided support the medical necessity of LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's care can be provided in the current 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 following a cerebrovascular accident (CVA), the enrollee was intubated and required a feeding tube. Later she failed swallow evaluation but was able to be weaned from ventilator support and uses tracheostomy. The enrollee's current needs include PEG tube placement, additional monitoring of baseline chronic conditions, and initiating some form of physical therapy. The enrollee's chronic conditions appear to be stabilizing. Although additional acute care is needed, there was no clear indication that more than 25 days of acute care would be needed or that there were any services at the LTACH that were not already being provided or can be provided at the current acute care facility. When the enrollee is more stable, discharge to a lower level of care should be sufficient to help management her chronic clinical 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: 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 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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided through home-based and outpatient 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia 60mg/ml syringe (J0897).You asked the Plan to pre-approveProlia 60mg/ml syringe. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia 60mg/ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drug would 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 Prolia 60mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60mg/ml syringe (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on April 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar and the wrist hand orthoses provided on September 23, 2019.
You asked the Plan to pay for the cervical collar (L0180)and the wrist hand orthoses (L3916). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services
have not been met.
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 was 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. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the cervical collar and the
wrist hand orthoses provided on September 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on August 13, 2019.You asked the Plan to pay forthe drugtesting services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.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 August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa for the enrollee.You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered under Part B.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 pre-approve Rhopressa for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran outpatient surgery provided on August 27, 2019 by an out of network (OON) provider.You asked the Plan to pay foran outpatient surgery. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran outpatient surgery provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the annual wellness visit, the annual depression screening, or the annual alcohol screening provided on September 30, 2019.You asked the Plan to reduce the coinsurance for the annual wellness visit, the annual depression screening, and the annual alcohol screening. You say that you do not agree with these charges. You say you were never told about out-of-network charges and assumed you would pay a $30 specialist copayment. 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 35% coinsurance for this out-of-network annual Medicare-covered wellness visit, 35% coinsurance for an out-of-network annual depression screening visit, and 35% coinsurance for the out-of-network Medicare-covered screening and counseling to reduce alcohol misuse preventive benefit. You have been asked to pay a total of $41.12 for the annual wellness visit, the annual depression screening, and the annual alcohol screening. The annual wellness visit falls within the "Annual wellness visit" benefit category. The annual depression screening falls within the "Depression screening" benefit category. The annual alcohol screening falls within the "Screening and counseling to reduce alcohol misuse" benefit category. The record shows the provider is out-of-network. 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 coinsurance forthe annual wellness visit, the annual depression screening, or the annual alcohol screening provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions, resin-based composites, and immediate dentures.You asked the Plan to pre-approve the dental extractions, resin-based composites, and immediate dentures. You say that you are embarrassed to leave your home because of your appearance. You say that you suffer from depression and avoid being social because of the condition of your teeth. You say that you have always kept good hygiene, but due to your prescribed medications, your teeth have gone bad. You say that you are now missing most of your teeth and the few you have left are broken.You say that your teeth have broken while eating, which has caused you to swallow them. You say that the teeth breath beneath the gums, which has caused you to have dozens of abscesses. You say that you have to worry about an infection traveling to your heart. You say that you have a hard time chewing and digesting food, which causes you to vomit. You say that you are disabled and on a fixed income. You say that you do not have the means to pay for your dental work.The Plan denied your request. The Plan says the benefit for extractions and resin-based composites has been exhausted. The Plan says that dentures are not a covered benefit under the enrollee's contract.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 coverage for extractions is limited to 3 per calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, the coverage for resin-based composites is limited to 2 per calendar year. The records show that the Plan approved coverage for 3 extractions (CPT D7210) and 2 resin-based composites (CPT D2331) on January 29, 2020. This means that your benefits for these types of services have been exhausted for the 2020 calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve dental extractions, resin-based composites, and immediate dentures.If you have questions regarding the Plan's authorization issued on January 29, 2020 for extractions and composites, you may contact the Plan directly.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on October 31, 2019.You asked the Plan to waive the copayment for an X-ray. You say that you were told that everything would be included in the $295 copayment for an outpatient procedure.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 $25 copayment for basic radiological services. You have been asked to pay a $25 copayment for an X-ray. An X-ray 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 an X-ray provided on October 31, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 16, 2019.You asked the Plan to waive the copayment for the office visit. You say that you were in the hospital on this date and did not received the services. 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 $10 copayment for each Medicare-covered primary care doctor visit. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record confirms that you received the office visit services on October 16, 2019.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on October 16, 2019.