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

We decided that the Plan does not have to pay for the telephone evaluation and management service (99443), the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), and the prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (99359) rendered by the out-of-network (OON) provider on February 18, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service (99443), the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), and the prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (99359) rendered by the out-of-network (OON) provider on February 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from February 12, 2021, through March 6, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day, for days 1 to 20 and a $184 copayment per day, for days 21 to 100, for in-network skilled nursing facility care.

You have been asked to pay $368 ($184 copayment x 2 days) for the skilled nursing facility care provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) care provided from February 12, 2021, through March 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep test (G0399).
You asked the Plan to pre-approve the home sleep test. You say that the test is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Home Sleep studies are only covered for the diagnosis of Obstructive Sleep Apnea. 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 home sleep test. Our reviewer says that the requested test is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of obstructive sleep apnea and is being treated with CPAP. The requested test is indicated to diagnose sleep apnea, which has already been done. 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 home sleep test have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep test (G0399).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on November 25,
2020.

You asked the Plan to pay for the laboratory testing. You say that the service should be covered as in network.
You say that you are sent specimens that ultimately determine the course of a person's treatment. The Plan
denied your request.

The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services
and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on November 25,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH have not been met. The Plan says that the enrollee can safely receive the care needed in another 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a total shoulder arthroplasty
(23472).
You asked the Plan to pre-approve an inpatient admission for a total shoulder arthroplasty. You say that this is
medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 an inpatient admission for a total
shoulder arthroplasty. Our reviewer says that the documentation does not support that the criteria for inpatient
admission are met in this case. Our physician reviewer found the enrollee is medically stable and has been
provided medical clearance to undergo this elective procedure. There is no documentation provided to support
the expectation the enrollee will require a greater than 2 midnight stay.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an inpatient admission for a total shoulder arthroplasty have not been met.
Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a total shoulder
arthroplasty (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64635, 64636).
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the patient must have had two (2) medically
reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of
80% relief of primary (index) pain.
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 injections. Our reviewer says that
the requested facet joint interventions are not medically necessary. Our physician reviewer found the enrollee's
provider has not confirmed facet joint pain relief by noting that two medial branch blocks (MBBs) provided at
least 80% improvement of the pain or that there was at least 50% improvement in the enrollee's ability to
perform daily activities. In addition, the enrollee has radiculopathy.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections (64635, 64636).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you would like to go to a SNF because
you do not want to be dependent on your wife. You also say that all of the doctors at the hospital have said you
will benefit from rehabilitation. The Plan denied your request. The Plan says you are medically stable, and you
do not have any skilled nursing needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or
skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs,
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the
SNF admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).
You asked the Plan to pre-approve the complete upper denture (D5110). You say that you couldn't find your dentures after leaving the hospital. You say that you can't eat proper food and want the upper denture granted. The Plan denied your request. The Plan says a complete upper denture (D5110) was approved on January 30, 2020 and you are not eligible again for this service until January 2025.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, a complete upper denture (D5110) is only covered once every five plan years. The Plan pre-approved a complete upper denture on January 30, 2020 and it was provided on February 5, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy duty extra wide hospital bed (E0303).
You asked the Plan to pre-approve the hospital bed. You say that due to the enrollee's medical problems including her weight, she is unable to utilize the standard hospital bed. She requires a heavy duty semi electric hospital bed to accommodate her weight. The Plan denied your request. The Plan says the enrollee does not meet the criteria because the records show that the enrollee weighs less than 350.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the heavy duty extra wide hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (93702).

You asked the Plan to pre-approve Bioimpedance spectroscopy. You say that please review the supporting documentation for coverage consideration. The Plan denied your request. The Plan says Bioimpedance spectroscopy is still being studied to see if the treatment is reasonable and necessary. There is lack of evidence to support this monitoring over traditional methods of evaluation.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (93702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ipilimumab (Yervoy).

You asked the Plan to pre-approve Yervoy. The Plan denied your request. The Plan says the requested drug Yervoy is considered experimental/investigational at this time for treatment of merkel cell carcinoma.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Yervoy. Our reviewer says that Yervoy is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has recurrent metastatic merkel cell carcinoma. The Medicare care approved compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical scenario. Our reviewer found that no literature from Medicare approved cancer journals was submitted with the review. There is insufficient literature to support the use of the requested agent in the enrollee's clinical situation. The requested service is not medically necessary and reasonable, as defined by Medicare rules, for the enrollee's clinical situation. Our physician reviewer also found that the elements of the coverage rule are not satisfied, and the requested service is not recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Ipilimumab (Yervoy).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on March 22, 2021.

You asked the Plan to pay for a crown, and a core buildup. You say that you were told the services would be covered at 50%. You are on a fixed income and cannot afford to pay the charges. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 a crown (D2740), and a core buildup (D2950) provided on March 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on February 19, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you were told that you would only owe a $5 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment for outpatient rehabilitation services. You have been asked to pay a $30 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on February 19, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee can be treated at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested SNF care is medically necessary in this case. Our physician reviewer found the enrollee does have documented skilled therapy needs and appears to be functioning below his baseline. Given multiple recent hospitalizations and surgery, a brief period of skilled therapy is reasonable to improve the enrollee's strength and endurance. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was
admitted to the hospital following an non-ST elevation myocardial infarction with acute on chronic congestive
heart failure. The enrollee continues to receive acute care services and these have not been denied. The medical
record does not indicate that the enrollee requires services that he is not currently receiving but that would be
available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.