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

We decided that the Plan does not have to pay for the skilled nursing services provided from August 24, 2019 to September 13, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says they had gone over the time frame to review this request.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 24, 2019 to September 13, 2019
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvebilateral removal of blood clot and portion of upper thigh artery.You asked the Plan to pre-approvebilateral removal of blood clot and portion of upper thigh artery. You say that the services are necessary.The Plandenied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 bilateral removal of blood clot and portion of upper thigh artery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation of significant, short distance claudication. There is also documentation of left iliac artery occlusion and extensive bilateral femoral disease based on the surgeon's review of the computed tomography (CT) angiogram. Multilevel disease including iliac artery occlusion and extensive femoral artery disease would be expected to create symptoms of a severity to warrant intervention. The proposed surgical plan is reasonable and includes back up plans for if the iliac occlusion cannot be crossed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral removal of blood clot and portion of upper thigh artery have been met.Therefore, we decided that the Plan has to pre-approvebilateral removal of blood clot and portion of upper thigh artery.  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 hasto 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs frequent lab draws, cardiac and pulmonary monitoring, and rehab therapy.The Plan denied your request. The Plan says the enrollee's medical condition appears stable, and does not need supervision by an inpatient rehab physician three times a week.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 physician reviewer found that the enrollee's current level of function is supine to sit with minimal assistance, sit to stand with supervision, and ambulating using a rolling walker with supervision. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 10, 2019 to September 8, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 10, 2019 to September 8, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) provided on October 21, 2019.You asked the Plan to pay fora tetanus, diphtheria toxoids and acellular pertussis vaccine. You say that you needed this vaccine to protect your granddaughter.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus, diphtheria toxoids and acellular pertussis vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus, diphtheria toxoids and acellular pertussis vaccine.Therefore, we decided that the Plan does not have to pay fora tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) provided on October 21,2019.Benefits for a tetanus, diphtheria toxoids and acellular pertussis vaccinemay 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on April 16, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you disagree with the increase of charges.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 Medicare Part B prescription drugs. You received a Medicare Part B drug injection on April 16, 2019. The allowed amount is $2,534.44 and 20% of that is $506.89. You have been asked to pay the total coinsurance amount of $506.89 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 fora Medicare Part B drug injection provided on April 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 11, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered on April 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 27, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 did not pre-approve the service 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 laboratory services provided on September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe insulin provided on October 1, 2019.You asked the Plan to pay forthe insulin. You say that the doctor stated that you needed the insulin.The Plan denied your request. The Plan says that this is 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 pay forthe insulin provided on October 1, 2019.Benefits for the insulinmay be available under Medicare Part D.Contactthe 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 medical services provided on October 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forvision services. You say that the enrollee currently resides at a nursing facility and relies on the facilities staff for all his needs. The physician is assigned to a facility and does not know which patient he'll be seeing.The Plan denied your request.The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.Medicare rules say that planscan require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Becaplermin gel (S0157) provided on February 27, 2019.You asked the Plan to pay for the Becaplermin gel. You say that you would like reconsideration as you have asked the provider to send a corrected claim. The Plan denied your request. The Plan says payment is not allowed for this service because the procedure code billed is not recognized by the health plan.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S0157 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S0157 has a status code of I. This means that S0157 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the Becaplermin gel have not been met. Therefore, we decided that the Plan does not have to pay for Becaplermin gel (S0157) provided on February 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on May 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered to the enrollee on May 3, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLucentis or Eylea intravitreal injections.You asked the Plan to pre-approvetheLucentis or Eylea injections. You say that you feel that the desired medication should be approved without a trial of the preferred drug.The Plan denied your request. The Plan says step therapy rules require a trial of Avastin for this condition.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 Lucentis or Eylea injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on step therapy requirements. Our physician reviewer found the enrollee has a diagnosis of Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization. The medical record notes Lucentis is recommended but the authorization request was made for Eylea. Both require a trial of Avastin prior to use. Bevacizumab (Avastin) has been used for many years as an off-label treatment for neovascular ARMD. Based on clinical trials, this medicationhas been demonstrated to be effective in the treatment of the enrollee's condition, and has a similar adverse event profile. Therefore, it is unlikely that the required drug, Bevacizumab, would be less effective, and/ or would have adverse effects for theenrollee in this case.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 Lucentis or Eylea injections have not been met.Therefore, we decided that the Plandoes not have to pre-approveLucentis or Eylea intravitreal injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SNF admission.You asked the Plan to pre-approvethe SNF admission. You say that you have many acquaintances who have been supplied with such care after far less severe situations.The Plan denied your request. The Plan says the service 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 the SNF admission. Our reviewer says that the enrollee doesnot meetthe Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe manual therapy techniques provided on September 9, 2019.You asked the Plan to pay forthe chiropractic care. You say that you were never informed that you needed a referral from your primary care physician in order for the service to be covered.The Plan denied your request. The Plan says that your primary care physician did not refer you for the services. The Plan says that you self-referred for the service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a full copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe manual therapy techniques provided on September 9, 2019.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 waive the copayments forthe  office visit or the laboratory services provided on July 18, 2019.You asked the Plan to waive the copayments forthe office visit and laboratory services. You say that you are on a fixed income and did not expect a bill three months after the services.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each in-network Medicare-covered visit with a primary care physician and a $35 copayment per day, per provider, for in-network Medicare-covered lab services. Youhave been asked to pay a $20 copayment for the office visit and an $18.67 copayment, which is less than the standard amount for the laboratory services. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory services fall 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 forthe office visit or the laboratory services provided on July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs inpatient rehabilitation.The Plan denied your request. The Plan says the enrollee could be treated 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 is medically stable with no evidence of need for physician supervision or for acute rehab nursing care. She may benefit from further physical and occupational therapy but does not require an intensive IRF program. IRF admission is not medically necessary based on her current functional status and medical stability.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-approveacute inpatient rehabilitation facility (IRF) admission and services.