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

We decided that the Plan does not have to pre-approve Gelsyn-3 injection (J7328).
You asked the Plan to pre-approve Gelsyn-3 injection, Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg (J7328). You say that the Plan said this is a covered medication with coinsurance and no mention was made that this was not a preferred medication and other brands needed to be tried first. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc, Synvisc and Synvisc One.
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 Gelsyn-3 injection, Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg (J7328). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 injection, Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg (J7328) have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 injection (J7328).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an interdisciplinary approach to rehab care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that you are at an independent assist level for eating, supervision for grooming and bathing, standby assist for dressing, and minimal assist for toileting. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient pelvic floor therapy to be provided the
requested out-of-network provider.
You asked the Plan to pre-approve outpatient pelvic floor therapy to be provided by the requested out-ofnetwork
provider. The Plan denied your request. The Plan says you must receive your care from a network
provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our
plan's network) will not be 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 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 outpatient
pelvic floor therapy to be provided by the requested out-of-network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ropinirole tab.
You asked the Plan to pre-approve Ropinirole tab. You say that because of a trial of other drugs it is medically necessary for the enrollee to switch to this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Ropinirole tab.
Benefits for Ropinirole tab 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that because of the length of your members legs she
needs the shoe lift. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by an out-ofnetwork
provider on February 16, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you think your copayment
should be $30. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $60
copayment for physician/practitioner services/out-of-network/specialty.
You have been asked to pay a $60 copayment for specialist services. The correct copayment has been applied.
Specialist services fall within the physician/practitioner services/out-of-network/specialty 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 specialist services provided by an out-of-network provider
on February 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health services from July 31, 2021, forward.
You asked the Plan to pre-approve the home health services. You say that you are an extreme risk for falling as you have poor body strength. You state you need home care services to develop strength. The Plan denied your request. The Plan says continued skilled physical therapy services are not indicated as you do not require hands on assistance, there is no signed physician order, and you appear to be at your baseline level of function.
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 the home health services. Our physician reviewer found the documentation does not support that you require skilled rehab services to provide treatment that is medically necessary. You do not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You appear to be at your baseline level of function. The requested home health services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of home health services from July 31, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2799).
You asked the Plan to pre-approve the services. You say that the tooth is cracked inside top to bottom. The
Plan denied your request. The Plan says this is not a covered benefit.
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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental services (D2799).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the longer you are in the hospital the less treatment you receive. You state with the COVID surges it puts you are a greater risk. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 you do not meet Centers for Medicare and Medicaid Services (CMS) criteria for an IRF admission. You are medically stable with no evidence of need for supervision by acute rehab physical medicine and rehabilitation (PMR) physician. You may benefit from further physical therapy (PT) but do not require an intensive therapy program in an IRF. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan of the thorax (71260) provided on January 12 and May 6, 2021.
You asked the Plan to waive the copayments for CT scans of the thorax. You say that the services at issue should be covered at no cost as they are directly related your COVID-19 diagnosis. The Plan denied your request. The Plan says the correct copayments were applied.
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 $150 copayment for each advanced imaging service. The case record does not contain documentation to support that CT scans of the thorax were performed due to a COVID-19 diagnosis. You have been asked to pay a $150 copayment for each instance of a CT scan of the thorax. CT scans of the thorax 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 copayments for a CT scan of the thorax (71260) provided on January 12 and May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need the rehabilitation to get back your regular life, you cannot walk on your own or stand. You state you are at a fall risk and do not have anyone at home. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 you do not meet Centers for Medicare and Medicaid Services (CMS) criteria for an IRF admission. You are medically stable with no evidence of need for supervision by acute rehab physical medicine and rehabilitation (PMR) physician. You may benefit from further physical therapy (PT) but do not require an intensive therapy program in an IRF.
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

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 a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 28, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied due to the enrollee's inpatient status at the time.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

In this case, the CPT Code Manual definition of the denied Healthcare Common Procedure Coding System (HCPCS) codes is:

HCPCS A0425: 

Ground mileage, per statute mile 

HCPCS A0427: 

Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency)

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the record indicates that an ambulance bill for date of service December 28, 2020 was submitted. The enrollee was an inpatient from December 26, 2020 through January 4, 2021. The requested service is not properly billed. The coverage rules are not satisfied. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care for shoulder surgery.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says you will not require a greater than two midnight stay.

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 pre-approve inpatient services. Our physician reviewer found that you are medically stable. You do not have a condition that requires inpatient care. The record does not show that your necessary care for the approved shoulder surgery will span two 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care for shoulder surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The
Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vision exam provided on March 23, 2021.

You asked the Plan to waive the copayment for the vision exam. You say that the visit was for a routine eye exam and you should not have a copayment for an ultrasound since this was a routine eye exam visit. The Plan denied your request. The Plan says it was determined that you received a non-routine vision exam, which requires a $45 copayment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for vision care, Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.

You have been asked to pay a $45 copayment for the vision exam. The vision exam falls within the vision 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 a vision exam provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard test.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements were not met.
The Plan must follow Medicare rules. The rules say that the Cologuard test is covered for enrollees between 50 and 85 years old. The enrollee is 90 years old, which is over the age range for this request. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cologuard test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239)
provided on October 7, 2020.

You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that the copayment
should be written off because you cannot afford to pay. The Plan denied your request. The Plan says the correct
copayment was applied.

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 $275
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.

You have been asked to pay a $275 copayment for an esophagogastroduodenoscopy. An
esophagogastroduodenoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 esophagogastroduodenoscopy (43239) provided on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided November 24, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you are being charged for inpatient hospital services incorrectly. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $350 copayment for outpatient surgery provided at hospital outpatient facilities. You have been asked to pay a $350 copayment for the outpatient surgery. This service falls within the outpatient surgery provided at hospital outpatient facilities benefit category. In this case, you are not being charged for an inpatient hospital stay but instead for the outpatient surgery performed at an outpatient hospital facility. 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 outpatient surgery provided November 24, 2020.