Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.

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 care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for admission level of care services after the emergency room evaluation. There was no documentation provided necessitating post-stabilization care services at the non-Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

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 care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifty-four (54) additional home health visits.

You asked the Plan to pre-approve additional home health visits. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health visits. Our physician reviewer found the records show do not show that more skilled nursing (SN) services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration at this time beyond what was already approved. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. As the documentation does not reveal more SN or skilled therapy services are required at this time the requested services do not meet the definition of home health aide services as per Section 50.2 and the request for additional home health services is excessive and not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fifty-four (54) additional home health visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amphetamine-dextroamphetamine tablets.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve amphetamine-dextroamphetamine tablets.

Benefits for these services may 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

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 had network providers available who could have provided the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the new patient office visit and the comprehensive hearing test.

You asked the Plan to waive the copayment for the office visit and hearing test. You say that you were told there would be no copayment for a routine hearing exam. The Plan denied your request. The Plan says you did not receive a routine exam.

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 $35 copayment for Physician/Practitioner services and a $10 copayment for outpatient diagnostic tests. 

You have been asked to pay a $35 copayment for the specialist visit and a $10 copayment for the comprehensive hearing test. The office visit falls within the Physician/Practitioner services benefit category. The hearing test 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 the new patient office visit and the comprehensive hearing test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this item is not
a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the expectation does not exist that ongoing physical therapy will result in practical improvement in level of function within a defined period of time.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the documentation does not indicate that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee should be able to transition to an independent home exercise program at this point. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your Part B plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the anesthesia services (00400 and 99100).

You asked the Plan to hold you harmless for the anesthesia services. You say that you would like
reconsideration because you are being billed the full cost of these services. The Plan denied your request. The
Plan says that this claim has not been billed with the appropriate modifier.

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 follows these rules.

You were referred for the anesthesia services by a contract provider. The file does not show that the Plan
provided notice that the anesthesia services would not be covered. Under Medicare rules, this means the
anesthesia services is considered approved by the Plan. Additionally, the Plan has indicated that you do not
have any liability for this claim. Therefore, we decided that the Plan has to hold you harmless for the anesthesia
services (00400 and 99100).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous spacer device (22869).

You asked the Plan to pre-approve the insertion of an interspinous spacer device. You say that this is medically
necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of an interspinous spacer
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in
this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature
do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of
this device for this enrollee's medical condition.

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 insertion of an interspinous spacer device have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of an interspinous spacer device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health service (H0018) rendered by the out of network (OON) provider.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the behavioral health service (H0018) rendered by the out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous spacer device (22869, 22870).

You asked the Plan to pre-approve the insertion of an interspinous spacer device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of an interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has generalized osteopenia, complete loss of intervertebral disc space at L1-L2; narrowing at L4-5 and complete loss of disc space at L5-S1 and thus overall would not meet FDA indications. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. There is imaging evidence of retrolisthesis of L2 over L3 with no discussion of spinal instability on flexion/extension films. There is no discussion indicating that a DEXA scan has demonstrated no significant osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition.

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 insertion of an interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interspinous spacer device (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc injections (J7327).

You asked the Plan to pre-approve Monovisc. You say that Monovisc is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 Monovisc. Our reviewer says that Monovisc is not medically necessary. Our physician reviewer found the patient has not failed a trial of physician-directed exercise or 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 Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc injections (J7327).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary. The Plan denied your request. The Plan says a trial of Euflexxa, SupartzFX, Durolane, and Gelsyn-3 is required before Orthovisc can be considered.

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 Orthovisc. Our reviewer says that Orthovisc is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ferumoxytol injection.

You asked the Plan to pre-approve the injection. You say that this is needed for treatment of iron deficiency anemia. The Plan denied your request. The Plan says there is no documentation of intolerance to oral iron.

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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no documentation that the enrollee is intolerant to oral iron and that her ferritin concentration meets the guidelines to establish the diagnosis. The review has determined that the requested Ferumoxytol injection 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 Plan does not have to pre-approve ferumoxytol injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You continue to require skilled therapy services on an intermittent basis. Although you are making slow progress with therapy, there is no indication that transfer to a SNF is required. You can continue to received skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.

You asked the Plan to pre-approve the maxillary partial denture. You say that your current denture is broken.
The Plan denied your request. The Plan says this service is allowed one time every sixty months. The Plan also
says that you had this service less than sixty months ago.

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, dentures are limited to one set every
five years. The record shows that you received a maxillary denture and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.