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

We decided that the Plan does not have to waive the coinsurance for DME.

You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you did not receive a walker and were out of it if you signed anything. 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 20% coinsurance for DME and related supplies.

You received DME. The allowed amount is $99 and 20% of that is $19.80.

You have been asked to pay the total coinsurance amount of $19.80 for DME. DME falls within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until December 10, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
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 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pleural effusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services.

You asked the Plan to waive the copayment for the inpatient rehabilitation. You say that you had already been in the hospital for two weeks. The Plan denied your request. The Plan says that admission records show that you were transferred to a separate hospital facility and therefore the copayment for the dates in question applies.

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 $300 copayment for each of the first five days of inpatient hospital care.

You have been asked to pay a $1500 copayment for 7 days of inpatient rehabilitation. Days 1-5 each require a $300 copayment, and there is no cost-share requirement after the fifth day. Inpatient rehabilitation falls within the inpatient hospital 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 inpatient rehabilitation services.
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 clinical information provided supports the need for LTACH care. The Plan denied your request. The Plan says the enrollee's medical condition requires an extended period of acute hospital care.

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 appears to be more stable but requires additional short-term acute care services to help further stabilize the enrollee prior to transfer, which can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires now that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed and the enrollee is more stable. 

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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a stress echocardiogram.

You asked the Plan to pre-approve a stress echocardiogram. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a stress echocardiogram is covered for the indications established in the applicable LCD. 

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 stress echocardiogram. Our reviewer says that a stress echocardiogram is medically reasonable and necessary in this case. Our physician reviewer found that as the enrollee is at high risk for significant atherosclerotic CAD, and his EKG stress was equivocal, further refinement of the diagnosis now requires an imaging stress test. A stress echocardiogram is therefore appropriate based on the LCD rules.

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 stress echocardiogram have been met. Therefore, we decided that the Plan has to pre-approve a stress echocardiogram.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula (nutritionally complete with intact nutrients).

You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your request. The Plan says the use of formulas as a convenient alternative to preparing and/or consuming regular solid or pureed foods is excluded from coverage.

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 formula. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided and reviewed, oral supplementation is not a covered benefit under Medicare and excluded from coverage. The reviewed documentation indicates that the enrollee does not meet the criteria for this request.

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 formula have not been met. Therefore, we decided that the Plan does not have to pre-approve enteral formula (nutritionally complete with intact nutrients).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cimzia powder for reconstitution 400mg (200mg x 2 vials) for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary and does not meet the step therapy criteria. Our physician reviewer found in this case the enrollee has been on Humira with good efficacy. The enrollee does not want to use Humira or Enbrel because of cost. The documentation does not address any of the other alternatives the plan requires. The documentation provided does not provide a sufficient medical rationale why the plan's alternatives would not be appropriate for the enrollee. Therefore, the enrollee does not meet step therapy criteria or exception criteria and the requested drug cannot be recommended.

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Cimzia powder for reconstitution 400mg (200mg x 2 vials) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for the inpatient hospital services.

You asked the Plan to hold you harmless for the inpatient hospital services. You say that you would like reconsideration as both the Plan and hospital have mishandled your medical emergency. The Plan denied your request. The Plan says that your care could have been received at an alternate level such as short stay or observation.

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 inpatient hospital services by a contract provider. The file does not show that the Plan provided notice that the inpatient hospital services would not be covered. Under Medicare rules, this means the inpatient hospital services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the inpatient hospital services.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633) for the enrollee.

You asked the Plan to pre-approve the services. You say that this procedure is to ablate the third occipital nerve [C2-C3]. You state the enrollee did well with occipital nerve blocks and noted good but temporary relief from the blocks. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The Plan reviewed the claim history and confirmed radiofrequency ablation (RFA). Both services were performed on the cervical area. For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the interlaminar device is experimental. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Stretta Procedure (43257).

You asked the Plan to pre-approve a Stretta Procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says there is insufficient published scientific evidence to support the effectiveness of these interventions, especially with respect to long-term outcomes.

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 Stretta Procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the Stretta procedure has not been studied nor expressly approved in patients with Barrett's esophagus.

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 Stretta Procedure have not been met. Specifically, there is insufficient evidence of the effectiveness of this service for the member's diagnosis. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a Stretta Procedure (43257).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex device, a
minimally invasive surgical procedure that is utilized to relieve the symptoms of lumbar spinal stenosis)
(22869, 22870).

You asked the Plan to pre-approve Vertiflex device. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is experimental and investigational.

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 Vertiflex device. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Spinous process distraction device is experimental. More research is needed to show safety
and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex device have not been met. Specifically, the requested service is
experimental. This means the service is not medically necessary or reasonable. Therefore, we decided that the
Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex device, a minimally invasive
surgical procedure that is utilized to relieve the symptoms of lumbar spinal stenosis) (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer device.

You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device
is medically necessary. The Plan denied your request. The Plan says the requested device 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 device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this device is experimental and more research is needed to show its safety and efficacy.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex Interspinous Spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the bed. You say that you are unable to use your right, and you live alone. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered more than once every five years.

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. The Plan covers the dentures when the services are medically necessary and reasonable.

We looked at the the file and plan contract rules. Dentures were last received less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxervate.

You asked the Plan to pre-approve Oxervate. You say that treatment with Oxervate is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication does not fall under Part B. The Plan also says that outpatient prescription drugs are not covered by the Plan.

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 Oxervate.

Benefits for Oxervate 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that you would like help covering these dental bills. The Plan denied your request. The Plan says these services are not covered benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services.