Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Genicular Nerve Block (64450).You asked the Plan to pre-approvea Genicular Nerve Block (64450). You say that the requested Genicular Nerve Block is medically necessary.The Plan denied your request. The Plan says the requested Genicular Nerve Block 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 a Genicular Nerve Block (64450). Our reviewer says that the requested Genicular Nerve Block is not medically necessary. Our physician reviewer found this enrollee has left knee osteoarthritis. She is obese and her surgeon told her that she has to lose 100 lbs. before she is a suitable candidate for a total knee replacement. She received a prior genicular nerve block which produced long lasting analgesia and the request is for another genicular nerve block. This is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, the request is deemed not medically reasonable or necessary 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 Genicular Nerve Block (64450) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Genicular Nerve Block (64450).
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 LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee can stay in this facility.
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 The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe medical services to be provided by an out of network (OON) neurologist.You asked the Planto pre-approvethe OON neurology services. You say that you have seen this provider in the past and do not wish to change to another neurologist. This provider has your history and your tremors have worsened since your last visit.The Plandenied your request. The Plansaysyou have not been seen by the OON neurologist since 2018. You are not receiving active treatment. There is no evidence that your condition is such that only this OON provider could treat you. There are several network neurologists in your area who can assume your care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/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 Plandoes not haveto pre-approvethe medical services to be provided by an out of network (OON) neurologist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on November 13, 2018.You asked the Plan to waive the copayment forthe ambulance ride. You say that you do not agree with the copayment because the ambulance ride was a result of a colonoscopy. You would like the claim to be paid as an extension of the colonoscopy. 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 $250 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 forthe ambulance ride provided on November 13, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and abdominal wall cellulitis in the setting of morbid obesity. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains critically ill and is noted to not be appropriate for ventilator weaning. Her long-term prognosis appears poor. 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that the enrollee has repeated falls.The Plan denied your request. The Plan says the admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services.Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the hospital on January 17, 2020 with right shoulder pain and limited range of motion. He was found to have a left humeral fracture andfitting with a sling with outpatient follow up. He was admitted for bilateral humerus fracture and underwent a left shoulder replacement on January 28, 2020. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine transportation trips exceeding 50 miles each way.You askedthe Plan to pre-approvethe one-way routine transportation trips. You say that you require this transportation in order to be trained by an occupational therapist in using a Myomo device and to receive intense physical therapy. You say that the occupational therapist at the requested location is the closest trained professional for the Myomo device.The Plan denied your request. The Plan says the requested services exceed the benefit limitations and are not covered by your health plan.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one-way routine transportation trips when each trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. We found that the location which you are requesting routine transportation to is more than 50 miles from your home address. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveroutine transportation trips exceeding50 mileseach way.
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 medically 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. In this case, the member is mostly MIN assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 drug testing coded G0483 provided on September 20, 2019.You asked thePlan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and(3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483 provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on June 25, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says there was no current examination indicating the need for this orthosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at review, the file and Medicare rules. The medical records are not recent and do not support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 9, 2019.
You asked the Plan to pay the full amount for the dental services. You say that you called the Plan because you received a bill. You say that you were advised the provider's contract had ended for the year. You also say that you were not informed that the provider was no longer contracted with the Plan. The Plan denied your request. The Plan says you are responsible for a 50% cost share for services that you receive out of network. The Plan also says that out of network providers can bill for all charges, including excluded charges.
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 and the dental services you received are listed as covered services, you are responsible for the 50% coinsurance that is applicable to dental services you receive out of network. Therefore, we decided that the Plan does not have to pay the full amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 9, 2019.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the enrollee can safely receive the services required in another setting.
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 enrollee's medical conditions appear stable and there are no wound care needs. The enrollee is currently in an outpatient setting and does not require any acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, the enrollee is ambulating near household distances and performing activities of daily living with minimal assistance and does not require an intensive rehabilitation therapy program. The enrollee is limited by debility and the severity of her comorbid medical conditions. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. 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 a trial of home based care or at a skilled nursing facility level. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after February 6, 2020.You asked the Plan to pre-approve continued SNF care. You say that the enrollee is unable to ambulate at home and needs rehabilitation.The Plan denied your request. The Plan says the denial of authorization for additional SNF care is correct, because neither Medicare nor the Plan covers SNF care beyond 100 days per benefit period.The Plan must follow Medicare rules. The rules say thatenrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from October 9, 2019 to February 6, 2020. The Plan has covered at least 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is notrequired to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvecontinued Skilled Nursing Facility (SNF) care after February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided by an out of network orthopedic provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says a second opinion is covered with an in-network provider.
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 physician's services for a second opinion to be provided by an out of network orthopedic provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the CT scan provided on August 12, 2019.You asked the Plan to reduce the copayment forthe CT scan. You say that the Health Plan advised you that there would be a $20 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 a $200 copayment for CT scans performed by an in-network provider other than your primary care physician. You have been asked to pay a $200 copayment for the CT scan. The CT scan 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 reduce the copaymentforthe CT scan provided on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on September 9, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that this was a critical scan. You say that there was no help with the cost.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment for CT scan. The enrollee has been asked to pay $97.47, which is less than the standard$125 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe CT scan provided on September 9, 2019.