Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PuraPly wound care services.You asked the Plan to pre-approve PuraPly. You say that you need the wound closed before you can have surgery.The Plan denied your request. The Plan says there is inadequate evidence to support clinical effectiveness.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 PuraPly. Our physician reviewer found that you have a traumatic wound on your right lower leg. You have been receiving care at a wound care and hyperbaric medicine center. A progress note states the wound is a vasculitic ulcer. Care included debridement and local wound cover and care. Review of the literature does not include substantial support for the use of the requested product for this diagnoses. Therefore, the requested wound care is not medically reasonable or necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PuraPly have not been met. Therefore, we decided that the Plan does not have to pre-approve PuraPly wound care services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency neurotomy (C4-C5/C5-C6).You asked the Plan to pre-approve radiofrequency neurotomy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy is only covered for certain indications.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 radiofrequency neurotomy. Our reviewer says that the documentation does not support that the requested injections are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of cervical spondylosis with radiculopathy, chronic pain, and opioid dependence. The enrollee received bilateral cervical facet joint injections with 80% pain relief reported for a few days. There is no non-facet pathology that could explain the source of the enrollee's pain, such as fracture, tumor, infection, or significant deformity. Clinical assessment implicates the facet joint as the putative source of pain. Thermal Medial Branch Radiofrequency Neurotomy is indicated only when dual Medial Branch Blocks provide greater than 80% relief of the primary or index pain and duration of relief is consistent with the agent employed. The treatment method used must be thermal and non-pulsed. Therefore, the enrollee does not meet criteria for the requested 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 radiofrequency neurotomy have not been met.Therefore, we decided that the Plan does not have to pre-approve radiofrequency neurotomy (C4-C5/C5-C6).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's rehab
needs are not complex, and he does not need a rehab physician three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He had a fall and fractured his
hip. Surgical repair was uncomplicated. All chronic medical problems are stable. There is no complicated
nursing or wound care needs. There is no documentation that shows the enrollee requires management three
days a week by a rehabilitation physician. While he does have a documented need for physical and
occupational therapy, the medical record does not support a need for an intensive rehabilitation therapy
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology services provided on March 31, 2020.
You asked the Plan to waive the copayment for the dermatology services. 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 a specialist visit on the date of service at issue in this appeal. The Plan says that 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 $50 copayment for specialist visits. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received dermatology services on March 31, 2020. You have been asked to pay a $50 copayment for the dermatology services. The dermatology services fall within the Physician/Practitioner 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 for the dermatology services provided on March 31, 2020.
Your complaint about how you feel the provider should have cancelled your appointment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided February 9, 2020 to February 10, 2020.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $50 copayment for Emergency Care. You have been asked to pay a $50 copayment for the Emergency Room Services. The Emergency Room Services falls within the Emergency 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 Emergency Room Services provided February 9, 2020 to February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 15, 2019.
You asked the Plan to pay for the laboratory 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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from January 21, 2020 through February 3, 2020.You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states the enrollee will not be responsible for inpatient copay beyond January 21, or for the cost of this admission except for their copay.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient mental health care. Our physician reviewer found the health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 21, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 mental health care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from January 21, 2020 through February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gammagard injection.You asked the Plan to pre-approve Gammagard.You say that IVIG is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the medication is considered investigational for the enrollee's diagnosis.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Gammagard. Our physician reviewer found that the requested use of Gammagard FDA-approved for the enrollee's diagnosis. Gammagard is not supported without documentation of recurrent infections. Therefore, the documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Gammagard have not been met.Therefore, we decided that the Plan does not have to pre-approve a Gammagard injection.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the continued SNF services after January 17, 2020.
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee required no nursing services which would be considered skilled services by Medicare.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 17, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for the continued SNF services after January 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on March 12, 2020.You asked the Plan to waive the copay for the ambulance transport. You say that you should not have to pay for this since you did not request the service.The Plan denied your request. The Plan says that the claim processed according to your benefits.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 $250 copay for Medicare-covered Ground Ambulance services. You have been asked to pay a $250 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered Ground Ambulance 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 copay for the ambulance transport provided on March 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
February 11, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that this is a financial
hardship for you. The Plan denied your request. The Plan says that you were charged 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 $90
copayment for Medicare-covered ambulance services per day.
You have been asked to pay a $90 copayment for the ambulance transport. The ambulance transport falls
within the Medicare-covered ambulance services per day 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 ambulance transport provided on February 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal provided on November 25, 2019.You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that there is no cost for a colorectal screening exam. 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 $100 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $100 copayment for the colonoscopy with lesion removal. The colonoscopy with lesion removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" category. The record shows a diagnosis code for benign neoplasm of colon, rectum, anus and anal canal and that the lesion was removed which makes the colonoscopy surgical in nature.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 colonoscopy with lesion removal provided on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 28, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 laboratory services provided on January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services.You asked the Plan to pre-approveinpatient psychiatric services. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the documentation does not support that the requested inpatient psychiatric services are medically reasonable or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on July 18, 2020 with Bipolar Disorder Type I Current Episode Manic without Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing any delusions or auditory/visual hallucinations while not showing any aggressive behaviors. The documentation doesnot support that is it medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as the enrollee did not have dangerousness to self or others. Based upon review the records provided for the admission, the enrollee does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to herself or others and no auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. Therefore, the enrollee does not meet criteria for the requested 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 inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for a lumbar epidural injection provided on February 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 clinic in this case is not a network provider with the Plan. 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 physician's services for a lumbar epidural injection provided on February 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services (74220) provided on March 4, 2020.You asked the Plan to pay for the x-ray services (74220). You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The Plan says payment for these services is the responsibility of the facility.The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.Therefore, we decided that the Plan does not have to pay for the x-ray services (74220) provided on March 4, 2020.