Persius/hicric huggingface dataset:
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 inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of an 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 based upon the review of available records, you are medically stable with no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or a need for acute rehabilitation nursing care. While you may benefit from continuing physical, speech, and occupational therapy, there is no evidence of a need for an intensive therapy program. Your rehabilitation needs can be met at a lower level of intensity setting such as in a skilled nursing facility. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested radiation treatment.You asked the Plan to pre-approve the radiation treatment. You say that the in-network provider performed 80-90 radiation treatments for several lesions on the enrollee's body that caused damage to his body. You say it was recommended by the enrollee's physician to go to the out-of-network provider for radiation treatment for a new lesion on his foot. The Plan denied your request. The Plan says the enrollee's Evidence of Coverage states care will be directed outside of the primary network only if it has been determined that they cannot provide the necessary care.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 provider with 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-approve the requested radiation treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that without proper support you are unable to walk or exercise. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring system.You asked the Plan to pre-approvea continuous glucose monitor. You say that the enrollee complains of painful fingersticks.The Plandenied your request. The Plan says the enrollee is not insulin treated or checking blood glucose four or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonableand necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Criteria is not met for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe 2 skilled nursing visits.You asked the Plan to pre-approvethe skilled nursing visits. You say that a new wound was found during the enrollee's last visit.The Plan denied your request. The Plan says the notes do not reflect a dressing that only a nurse can do, as even with the silvadene,the enrollee's daughter is doing it. The Plan also says that the assessment of the wound can be done by the enrollee's daughter and registered nurse visits offered in case it seems worse, but it was only improving during the period of provided notes.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked ourphysician 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 skilled nursing visits. Our reviewer says that the additional skilled nursing visits are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee beyond what was approved by the health plan. Our reviewer found that there are no complex wounds, intravenous medications, new enteral feedings or other skilled nursing need that require ongoing skilled nursing beyond what was already approved by the Plan. The Plan approved 5 additional visits to monitor the enrollee's condition. Our reviewer found that the enrollee's daughter is able to manage current wound care needs. Our physician reviewer also found that the request for the remaining 2 additional home health care skilled nursing visits are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. 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 visits have not been met.Therefore, we decided that the Plan does not have to pre-approvethe 2 skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 3, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you are appealing based on medical necessity.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this
provider is out-of-network with the Plan and 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 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 for the medical services provided on December 3,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient services provided on August 31, 2019 to September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forinpatient services. You say that these services were medically necessary.The Plan denied your request. The Plan says the member was stable enough to transfer to an approved facility.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that thePlan 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 topay forinpatient services provided on August 31, 2019 to September 11, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 18, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice consultations and treatment (99214) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe office consultations and treatment. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.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 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-approveoffice consultations and treatment (99214) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea shoulder arthroscopy with debridement for enrollee.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says that the services are 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 the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has persistent and worsening right shoulder pain. Functional limitations are noted in activities of daily living and recreational/exercise activities. Clinical exam findings have been consistent with imaging evidence of full thickness rotator cuff tear, rotator cuff tendinosis, acromioclavicular joint arthritis, biceps tendinosis, and degenerative labral fraying. She has failed to improve with reasonable long-term conservative treatment, including activity modification, medications, and exercise. Current evidence based medical guidelines and literature support surgical intervention as requested.Therefore, the requested right shoulder arthroscopic surgery would be considered the standard of care and medically reasonable and necessary for treatment of this enrollee's medical condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approvea shoulder arthroscopy with debridement for enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the urology supplies to be provided by an out of network provider.You asked the Plan to pre-approve the urology supplies. You say that the enrollee needs supplies.The Plan denied your request. The Plan says urology supplies are covered but can be provided by an in-network provider.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 provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items.Therefore, we decided that the Plan does not have to pre-approve the urology supplies to be provided by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
October 4, 2019 to October 31, 2019.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim
submitted with an inappropriate bill type for the RAP claim. Therefore, we decided that the Plan does not have
to pay for the home health services provided to the enrollee from October 4, 2019 to October 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 4, 2019 to June 27, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services. We looked at the file and Medicare rules. The claims were not billed with the correct TOB code. 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 for the home health services rendered from June 4, 2019 to June 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on December 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 the services are not covered.The Plan must follow Medicare rules. The rules say that the PC and TC are separately payable only when furnished in different payment localities.We looked at the file and Medicare rules. The file shows that the services at issue were rendered to the enrollee while inpatient at the hospital. The PC and TC were not performed in separate payment localities. 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 services rendered on December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy injection provided on October 29, 2019.
You asked the Plan to waive the coinsurance for the chemotherapy injection. You say that you cannot afford this medication. You say the price keeps going up. 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 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. You have been asked to pay $1,227.28 which is 20% of the allowed amount for the chemotherapy injection. The allowed amount is $6,136.40. ($6,136.40 x 20% = $1,227.28). The chemotherapy 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 for the chemotherapy injection provided on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic dental procedure (D3999) provided on December 7, 2019.You asked the Plan to pay for the endodontic dental procedure. You say that you were in severe pain due to a root canal. You also say that you knew it would not be covered but you were in severe pain.The Plan denied your request. The Plan says this service is not covered by your dental plan.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 pay for the endodontic dental procedure (D3999) provided on December 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio injections.You asked the Plan to pre-approvethe Zarxio injections. You say that this drug is needed for the patient's treatment regimen.The Plan denied your request. The Plan says the preferred drugs would be appropriate to try in this case, before approval of Zarxio.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 Zarxio injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on the step therapy criteria. Our physician reviewer found the enrollee does have a more than 20% risk of neutropenic fever based on age, prior chemotherapy, and neutropenia on current regimen. However, there is no documentation that the plan preferred drugs, Neupogen or Nivestym, would be less effective or cause adverse events.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 Zarxio injections have not been met.Therefore, we decided that the Plan does not have to pre-approveZarxio injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 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 for the medical services provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 3, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim was submitted with an invalid Type of Bill code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid Type of Bill code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 3, 2019.