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

We decided that the Plan does not have to pay for the extremity study (93971) rendered by the out-of-network (OON) provider on May 7, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the extremity study (93971) rendered by the out-of-network (OON) provider on May 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. 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 in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any documented skilled nursing or skilled therapy 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you cannot ambulate, feed, or dress yourself without assistance and are a fall risk. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 8, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 8, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (J7605).
You asked the Plan to pre-approve Brovana. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not medically necessary.
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 Brovana. Our reviewer says that the drug is not medically necessary. Our physician reviewer found a trial of drug Perforomist (formoterol) is required before the Plan will approve the requested drug. In this case, the patient has not tried and failed the required drug and there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Specifically, the enrollee has not tried and failed the Plan's required drug. This means the requested drug is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Brovana (J7605).
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not have rehabilitation needs from multiple therapy disciplines, would not benefit from an intensive rehabilitation program, do not have complex medical management needs, and do not require supervision by a rehabilitation physician.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for syncope and aortic stenosis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) and alveoloplasty (D7311).
You asked the Plan to pre-approve gingival irrigation (D4921) and alveoloplasty (D7311). You say that The Plan denied your request. The Plan says the services are 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 gingival irrigation (D4921) and alveoloplasty (D7311).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. 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 in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any documented skilled therapy or skilled nursing 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 SNF care have not been met. Specifically, medically necessary services can be obtained in a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placements, prefabricated abutments, abutment supported crowns and pontics for a fixed bridge for tooth #'s 3 to 14.
You asked the Plan to pre-approve the surgical implant placements, prefabricated abutments, abutment supported crowns and pontics for a fixed bridge. The Plan denied your request. The Plan says the requested fixed bridge replacing eight teeth is beyond the scope of the policy benefit coverage.
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, a fixed appliance is only covered to replace a single anterior tooth or two adjacent mandibular teeth. Therefore, we decided that the Plan does not have to pre-approve the surgical implant placements, prefabricated abutments, abutment supported crowns and pontics for a fixed bridge for tooth #'s 3 to 14.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you had at a freestanding laboratory on April 2, 2021.
You asked the Plan to waive the copayment for the lab services. You say that this service should be covered it full. The Plan denied your request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $20 copayment for lab services at a freestanding laboratory. You have been asked to pay a $20 copayment for the lab services. 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 lab services you had at a freestanding laboratory on April 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound exam of the abdominal back wall, limited (76775) provided on February 8, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $30 copayment for specialty physician for other Medicare-covered outpatient diagnostic tests. You have been asked to pay a $30 copayment for the Medicare-covered outpatient diagnostic test provided. 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 ultrasound exam of the abdominal back wall (76775) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0103, 36415, 80053, 80061) rendered by the out-of-network (OON) provider on April 27, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0103, 36415, 80053, 80061) rendered by the out-of-network (OON) provider on April 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71046) provided on March 16, 2021 by an OON provider.
You asked the Plan to pay for the chest x-ray. You say that the provider requesting this service is part of the Plan's network and should have requested authorization for the services. You also say that you should not be penalized for the provider neglecting to request authorization. The Plan denied your request. The Plan says prior authorization was not obtained.
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 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 for the chest x-ray (71046) provided on March 16, 2021 by an OON provider.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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. Specifically, medically necessary services can be obtained in a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord neurostimulator trial.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650). You say that the enrollee has chronic knee pain. The Plan denied your request. The Plan says an evaluation by a knee orthopedic surgeon, stating that no further surgery is recommended, was not submitted.
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 percutaneous implantation of neurostimulator electrode array, epidural (63650). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this request is for a Dorsal Root Ganglion stimulator not a spinal cord stimulator. There is no documentation of any reprogramming attempts or consultation with a surgeon. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural (63650) have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord neurostimulator trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit for an established patient (99213) and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral: optic nerve (92133) provided on June 9, 2020.
You asked the Plan to waive the copayment for the vision care services. You say that in the "what you must pay" column it states "$0 copayment per visit for Medicare-covered glaucoma screening and diabetic retinopathy screening." You say that it is your understanding that your visit has been specifically for the purpose of screening you for glaucoma. You also say that you do not understand why you are being charged a $35 copayment. The Plan denied your request. The Plan says there is a $35 copayment for the office visit. The Plan says that there is a $0 copayment for the scanning computerized ophthalmic diagnostic imaging. The Plan also says that the copayment was 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). Your contract with the Plan clearly says that you must pay $35 copayment for vision care. You have been asked to pay $35 copayment for the vision care. The vision care services fall 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 the office visit for an established patient (99213) and the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral: optic nerve (92133) provided on June 9, 2020.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being obtained at the enrollee's current level of care and would not receive any additional services at a LTACH. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.