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

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary, as the enrollee is legally blind and need help sitting and walking.The Plandenied your request. The Plansaysrestorative rehab was completed, and the enrollee are medically stable, with no daily skilled needs.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require continued 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. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee 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 thenecessary 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 25, 2019.
You asked the Plan to pay for the dental service. You say that you did not receive a periodic oral evaluation as this appointment was a follow up to assess the effectiveness of a previously performed periodontic deep-cleaning. The Plan denied your request. The Plan says the frequency limit of 1 periodic exam every 6 months has been exceeded.
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 and periodic exams are a covered service, the frequency limit has been exceeded. The record shows the Plan paid for the periodic exam that you received on June 3, 2019, less than 6 months prior. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Test Strips (A4253) beyond a 90 day supply approved by the plan.You asked the Plan to pre-approve the OneTouch Test Strips. You say that the test strips are medically necessary.The Plan denied your request. The Plan says a 90 day supply to allow transition to a plan preferred meter will be approved, but additional test strips by One Touch will not be covered.The Plan must follow Medicare rules. Medicare rules allow a plan to identify preferred brands for certain medical equipment and supplies. We looked at the file and Medicare rules. The requested One Touch strips are not a plan preferred brand. A note from the provider states that the enrollee is able to use the preferred brand. Based on this information, we decided that Medicare rules for coverage of the One Touch Test Strips have not been met.Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Test Strips (A4253) beyond a 90 day supply approved by the plan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forphysical therapy provided from October 7, 2019 through November 25, 2019.You asked the Plan to waive the deductible forphysical therapy. You say that you were informed you would have a $0 copayment.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paidthe deductible amount, you must pay the full cost of your covered services.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules byclearly disclosing in the contract that your $750 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time physical therapy was received on October 7, 2019 to November 25, 2019.Therefore, we decided that the Plan does not have to waive the deductible forphysical therapy provided from October 7, 2019 through November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) provided on October 18,
2019.
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration because
the member was seen in an emergency situation. The Plan denied your request. The Plan says observation care
may only be reported by the physician who ordered hospital outpatient observation services and was
responsible for the patient during his/her observation care.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IV Reclast (zoledronic acid).You asked the Plan to pre-approve the IV Reclast treatments. You say that the enrollee has used Reclast and needs this treatment to continue to prevent further bone loss.The Plan denied your request. The Plan says the enrollee does not have osteoporosis so this cannot be covered.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 the IV Reclast treatments. Our reviewer says that the requested drug is not considered medically reasonable and necessary. Our physician reviewer found documentation notes the enrollee was diagnosed with osteopenia in December 2018 with bone density testing. Approved compendia support the use of this medication for the diagnosis of osteoporosis. Without the support of the documentation, medical necessity cannot be determined.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 IV Reclast treatments have not been met.Therefore, we decided that the Plandoes not haveto pre-approve IV Reclast (zoledronic acid)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from October 4, 2019 to November 8, 2019.You asked the Plan to waive the coinsurance for the Part B injections. You say that that paying $88.24 for each injection is very expensive. You say the injections were covered in 2018 with no copayment and you need this injection weekly. 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% coinsurance for Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay $88.24 which is 20% of the allowed amount for the Part B injections on each date of service. The allowed amount is $441.20. ($441.20 x 20% = $88.24). ($88.24 x 6 dates of service = $529.44). The Part B injections fall 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 for the Part B injections provided from October 4, 2019 to November 8, 2019.Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by "the doctor".You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the services are not urgent or emergent and can be provided within the Plan's network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network providerwith the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvephysician's services to be provided by "the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit, the endovenous ablation therapy, and extremity test to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the physician services. The Plan denied your request. The Plan says the requested services can be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.You are not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the office visit, the endovenous ablation therapy, and extremity test to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvetrigger point injections and diagnostic occipital nerve blocks.You asked the Plan to pre-approvetrigger point injections and occipital nerve blocks. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the enrollee has not failed to respond to an adequate trial of conservative therapy and these treatments are not the standard of care for the enrollee's condition.The Plan follows Medicare rules. Medicare rules say that trigger point injections are used to treat the cause of pain, and occipital nerve blocks may be used to confirm a clinical impression of occipital neuralgia.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 trigger point injections and occipital nerve blocks. Our reviewer says that the enrollee meets the Medicare criteria for the requested trigger point injections and occipital nerve blocks. Our physician reviewer found the enrollee's headaches are described as mixed and migraine. There is an occasional occipital component to the headaches. The pain pattern is also described as radiating down to the shoulders and back. Trigger points were identified. The documentation submitted contains a detailed history and thorough physical examination documenting a painful condition with identification of trigger points and the presence of occipital neuralgia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of trigger point injections and occipital nerve blocks have been met.Therefore, we decided that the Plan has to pre-approvetrigger point injections and diagnostic occipital nerve blocks.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided February 28, 2019 to August 29, 2019.You asked the Plan to pay forthe dental services. You say that you should have been informed that the plan only uses in-network provider's instead of saying that you are good to use them.ThePlan denied your request. The Plan says enrollee's must receive their dental services from an in-network dental provider.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 health plan contract specifically says to be covered in-network you need to use a dentist in the dental network. Care rendered by a provider that is not a part of the dental network is not covered. 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 pay forthe periodontal maintenance (D4910) provided February 28, 2019 to August 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of careThe 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 is currently undergoing treatment at an ACH for respiratory failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrolleeis tolerating ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation to be provided at an out of network (OON) facility.
You asked the Plan to pre-approve the OON cardiac rehab services. You say that your caregiver has trouble getting you to the rehab sessions in Waco because of the distance. The Plan denied your request. The Plan says the in-network facility may be further than the OON site. but it is still considered accessible based on Medicare rules.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. Everest Rehab Hospital is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide the OON cardiac rehab services. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve cardiac rehabilitation to be provided at an out of network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 2 office visits, 2 blood draws, and 2 extremity studies to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the physician services. You say that the services should be approved based on continuity of care from July 23, 2018.The Plan denied your request. The Plan says the requested services can be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.You are not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the 2 office visits, 2 blood draws, and 2 extremity studies to be provided by an out of network (OON) provider.No continuity of care issue has been identified in this case
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services (T1019) provided on May 1, 2019.
You asked the Plan to pay for the personal care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not a Medicare covered benefit.
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 T1019 is not supported in the record. Specifically, per the National Physician Fee Schedule, CPT code T1019 has a status code of I. This means that T1019 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pay for personal care services (T1019) provided on May 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an acute inpatient rehabilitation facility admission.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 that the enrollee's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. The enrollee does not require medical oversight of her condition at an acute hospital level of care. She does require physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Speech therapy is indicated for assessing and treating impairments of language, cognition, and swallowing. However, she is ambulating greater than household distances and is performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided likely through home-based care with home health services or alternatively at a skilled nursing level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation facility care have not been met.Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Lupron (leuprolide acetate) injections.
You asked the Plan to pre-approve the Lupron injections. You say that this treatment is the standard of care for this enrollee's condition. The Plan denied your request. The Plan says that this enrollee has low risk cancer and does not require ongoing Lupron treatments.
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 the Lupron injections. Our reviewer says that the requested treatment regimen is shown to be medically reasonable and necessary. Our physician reviewer found this patient has biochemically(PSA) recurrent prostate cancer which, by definition, is considered advanced stage prostate cancer. If salvage options are not practical or unsuccessful, as in this case, androgen deprivation therapy (ADT) is a standard option for disease control. The requested use of Lupron is FDA-approved for the enrollee's diagnosis. As such, ongoing Lupron treatments are 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 the Lupron injections have been met. Therefore, we decided that the Plan has to pre-approve Lupron (leuprolide acetate) injections.