Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from February 3, 2018 to February 6,
2018.
You asked the Plan to pay for inpatient care. You say that this claim was filed timely. The Plan denied your
request. The Plan says this claim was filed more than a year after the date of service and original denial.
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 this claim for inpatient care was not filed until May 13, 2019. 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 inpatient care provided from February 3, 2018 to February 6, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. The Plan denied your request. The Plan says that the information received supports that therapy services might be appropriate on an outpatient basis.The Plan must follow Medicare rules. The rules say that Medicare paysfor 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the dental services provided by an international provider on October 23, 2019.
You asked the Plan to provide reimbursement for the dental services. You say that you went to a US born dentist who relocated to Peru and the staff members of the US embassy go to her. The Plan denied your request. The Plan says this request exceeds the limit of the $150 for the 2019 dental benefit allowance.
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. Records show that you were already reimbursed the $150 dental allowance on March 19, 2019. Therefore, we decided that the Plan does not have to provided reimbursement for the dental services provided by international provider on October 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from skilled nursing.
The Plan denied your request. The Plan says that the enrollee is medically stable and medical care can be
rendered at home with VNA services.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional months with a home ventilator (E0466).
You asked the Plan to pre-approve additional months with a home ventilator (E0466). You say that the additional months with a home ventilator are medically necessary. The Plan denied your request. The Plan says the additional months with a home ventilator are not medically necessary at this time.
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 additional months with a home ventilator (E0466). Our reviewer says that the additional months with a home ventilator are not medically necessary at this time. Our physician reviewer found the enrollee is with diagnoses of chronic obstructive pulmonary disease, unspecified, and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. Her past medical history includes sarcoidosis, stage IV lung adenocarcinoma, breast cancer, obesity, and obstructive sleep apnea. The enrollee has been hospitalized 7 times in the past year for respiratory failure. The plan notes that the enrollee meets criteria for a home ventilator, however, in the setting of not utilizing a previously provided machine, she does not meet home compliance documentation which excludes current approval of another machine. The enrollee appealed, stating that there was improvement while using the requested ventilator in the hospital. Consequently, an exception was made, and 3 months of coverage were approved. The plan required documentation of compliance and a utilization report prior to additional months being approved. Additional months of coverage beyond 3 months will be considered medically reasonable and necessary based upon documented compliance with the home ventilator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional months with a home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve additional months with a home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs supervision and ongoing rehab therapy. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy services.
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 SNF services. Our physician reviewer found that the enrollee's hypertension and anemia is stable. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not have a complex wound care or other SNF level skilled nursing need. His high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH serviceshave not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea Positron Emission Tomography (PET) scan (78608).You asked the Plan to pre-approvethe PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says that rules for coverage have 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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found per the documentation the enrollee's cognitive decline has continued over the past 6 months since the initial evaluation. An FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD.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 PET scan have been met.Therefore, we decided that the Plan has to pre-approvea Positron Emission Tomography (PET) scan (78608).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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc injections.
You asked the Plan to pre-approve Orthovisc injections. You say that the enrollee is not a candidate for surgery. The Plan denied your request. The Plan says that Orthovisc is not considered effective for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Orthovisc injections. Our reviewer says that Orthovisc injections are not medically necessary at this time. Our physician reviewer found current evidence based medical guidelines state that medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. This request for repeat viscosupplementation injections is reasonably indicated for treatment of the enrollee's bilateral knee pain due to end-stage osteoarthritis given the failure of other standard treatment to provide adequate relief and that she is not a surgical candidate. Therefore, the documentation would support that the Orthovisc injections are medically reasonable and necessary and safe and effective for treatment of this enrollee's bilateral knee end-stage osteoarthritis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc injections have been met. Therefore, we decided that the Plan has to pre-approve Orthovisc injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient hospital facility visit provided on August 22, 2019.You asked the Plan to waive the copayment fortheoutpatient hospital facility visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an outpatient hospital facility visit on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $25 copayment for Outpatient hospital services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you receivedphysician services provided in an Outpatient hospital facility on August 22, 2019. You have been asked to pay a $25 copayment for the outpatient hospital facility visit. The outpatient hospital facility visit falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient hospital facility visit provided on August 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from July 28, 2019 to August 4, 2019.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from July 28, 2019 to August 4, 2019.
Benefits for these services 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services (90837) provided on August 30, 2019. You asked the Plan to pay forthe psychotherapy services. You say that you did not know you needed preauthorization.The Plan denied your request. The Plan says there are in-network providers that can provide the services at issue.Medicare rules say that plans can require enrolleesto 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 isnot 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 forthese items/services.Therefore, we decided that the Plan does not have to pay forthe psychotherapy services (90837) provided on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegingival irrigation -per quadrant (D4921).You asked the Plan to pre-approvegingival irrigation -per quadrant. You say that the services are necessary.The Plan denied your request. The Plan says the requested service 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-approvegingivalirrigation -per quadrant (D4921).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveT10-pelvis fusion, L3-4 decompression, L5-S1 TLIF with BMP from a posterior approach.You asked the Plan to pre-approveT10-pelvis fusion, L3-4 decompression, L5-S1 TLIF with BMP from a posterior approach. You say that the requestedlumbar surgery with BMP from a posterior approach is medically necessary.The Plan denied your request. The Plan says that the requested lumbar surgery with BMP from a posterior approach is not medically necessary.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve T10-pelvis fusion, L3-4 decompression, L5-S1 TLIF with BMP from a posterior approach. Our reviewer says that the requested lumbar surgery with BMP from a posterior approach is medically necessary. Our physician reviewer found this enrollee is severely debilitated and indicated for T10 to pelvis deformity surgery. She is reported at high risk for fusion failure based on her osteoporosis. Surgery has been planned to include T10-pelvis fusion with an L3/4 decompression and L5/S1 TLIF using BMP from a posterior approach. Surgery has been denied as the FDA-approved use for BMP is an anterior approach. An anterior approach cannot be utilized in this case as the enrollee was status post multiple abdominal surgeries. Current evidence based medical literature has demonstrated the safety and effectiveness of off-label use of BMP in posterolateral fusion and TLIF procedures. The patient-specific surgical indications and comorbidities documented by the spine surgery support his assertion that the use of BMP for the posterior approach as standard of care in long deformity surgery. Therefore, the request for lumbar surgery with bone morphogenetic protein from a posterior approach is medically reasonable and 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 T10-pelvis fusion, L3-4 decompression, L5-S1 TLIF with BMP from a posterior approach have been met.Therefore, we decided that the Plan has to pre-approveT10-pelvis fusion, L3-4 decompression, L5-S1 TLIF with BMP from a posterior approach.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: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRI of the pelvis for the enrollee.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthe guidelines do not support additional imaging without knowing the outcome of the prior approval.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found in line with the AUA guidelines MRI of the surgically absent prostate would likely not be the procedure of choice. PET/CT would be the procedure to most likely yield the most diagnostic results.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 MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRI of the pelvis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Monurol Pak Granules medication.You asked the Plan to pre-approvethis medication. You say that this medication is medically necessary for the enrollee.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Monurol Pak Granules medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.