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

We decided that the Plan does not have to waive the copayment for an endoscopy provided by a participating provider on February 25, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you did not know that you were having an endoscopy until you were on the table. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment for outpatient surgery/outpatient hospital. 

You have been asked to pay a $250 copayment for an outpatient surgery. Since an endoscopy was provided, the correct copayment has been applied. An endoscopy falls within the outpatient surgery/outpatient hospital 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 an endoscopy provided by a participating provider on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with single power option and accessories.

You asked the Plan to pre-approve a group 2 power wheelchair with single power option and accessories. You say that the power wheelchair and accessories are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair with single power options is subject to the criteria listed in the Medicare rules section. 

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 a group 2 power wheelchair with single power option and accessories. Our reviewer says that the requested wheelchair is not medically reasonable and necessary. Our physician reviewer found that you do not meet the criteria for the group 2 power wheelchair with single power options (power tilt seating system). The documentation indicates that you are at mild risk for development of a pressure ulcer; therefore, the criteria that the patient must be at high risk for development of a pressure ulcer has not been met. The documentation does not reveal that you utilize intermittent catherization for bladder management or needs a power seating system to manage increased tone or spasticity. The criteria for the requested group 2 power wheelchair with single power options and accessories has not been met. Since the base wheelchair is not eligible for coverage, the related accessories are not eligible for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 power wheelchair with single power option and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with single power option and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 patient was admitted for aspiration pneumonia after a recent admission for myocardial infarction. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on December 16, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care 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 care provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of a power seat elevation system (E2300).

You asked the Plan to pre-approve a power seat elevation system. You say that this is medically necessary. The Plan denied your request. The Plan says the power seat elevation feature is non-covered because they are not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the replacement of a power seat elevation system (E2300).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76641) provided on March 16, 2021.

You asked the Plan to waive the copayment for an ultrasound of the breast. You say that the copayment is too much to pay for a service that was medically needed. You also say the provider requested you to get an ultrasound after your mammogram results and you feel that you should not be financially liable for the charge. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $75 copayment for outpatient diagnostic tests and therapeutic services and supplies including ultrasounds.

You have been asked to pay a $75 copayment for an ultrasound of the breast. The EOC confirms $75 is the required copayment for this service. An ultrasound of the breast falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound of the breast (76641) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on March 30, 2021.

You asked the Plan to pay for the eye exam. You say that the patient did not have any input in choosing who the optometrist would be and relied on the staff to ensure he received the exam. You say that the provider performing services in a nursing home is not responsible to obtain authorization and the doctor should be reimbursed for all services rendered. The Plan denied your request. The Plan says there was no authorization for out-of-network services.

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 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 eye exam provided by an out-of-network provider on March 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc and Monovisc.

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 Hyalgan. Our physician reviewer found that the enrollee has knee osteoarthritis. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The provided records do not clearly show that the enrollee tried and failed either Orthovisc or Monovisc prior to requesting Hyalgan. The Plan's required drugs are essentially equivalent in effectiveness and safety based on currently available comparison studies. Trying the preferred products would not be less effective or have more side effects. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is a 78-year-old man who was admitted to the acute care hospital on
August 18, 2021, with pneumonia which proved to be tuberculosis. In this case, the enrollee is receiving acute
hospital care, and acute care services have not been denied. The documentation does not support that the
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is
currently receiving care. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee 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 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from a strong clinical and interdisciplinary team. The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the acute care hospital.
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 physician reviewer found that the enrollee was admitted to the current acute care hospital with weakness and confusion, heart failure, kidney failure, and respiratory failure r. Recent notes state the enrollee is more stable and improving but refusing tests. She appears to be improving and only requires additional short-term acute care services for additional weaning and therapy, which can safely be administered at the current facility. She does not require services at the LTACH that are not already available at the current facility. Transfer at this time would not provide a significant clinical advantage. Therefore, this request for LTACH services will be considered not medically 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on November 11, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that an authorization is not needed for office visits and you would like a review for payment. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99213) provided on November 11, 2020, by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Avastin.

You asked the Plan to provide coverage for Avastin. You say that this drug is medically necessary for the
enrollee. The Plan says that Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Avastin.
The QIC Physician Reviewer determined that the medication is necessary. The Plan requested a reopen
and states the guidelines for this drug do not show any covered indications related to the use of bevacizumab
(Avastin) intravitreal as adjunct treatment to brachytherapy. The Plan is correct in this case. The documentation
does not show the enrollee has a covered off-label indication for use of this drug.

We looked at this review and the Medicare rules. Based on this information it has been determined the
Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to provide coverage
for Avastin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy bra (L8000) and breast prosthesis (L8030).
You asked the Plan to pre-approve a mastectomy bra and breast prosthesis. You say that the requested equipment is necessary due to a congenital condition. The Plan denied your request. The Plan says this is not a covered service when not performed after a medically necessary mastectomy.
The Plan must follow Medicare rules. Medicare rules say that in order for the breast prosthetic and bra to be covered, the enrollee must have had a medically necessary mastectomy. We looked at the file and Medicare rules. In this case, you have not had a medically necessary mastectomy as required by the Medicare requirements. Based on this information, we decided that Medicare rules for coverage of a mastectomy bra and breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy bra (L8000) and breast prosthesis (L8030).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) and four 2D oral/facial photographic images (D0350 x4) provided on April 22, 2021.

You asked the Plan to pay for the additional intraoral periapical x-rays and 2D oral/facial photographic images. You say that you did not agree to pay for x-rays and an exam. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify 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 the two additional intraoral periapical x-rays (D0230 x2) and four 2D oral/facial photographic images (D0350 x4) provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and lenses (V2784) provided on January 16, 2021.
You asked the Plan to pay for eyeglass frames and lenses. You say that the requested items were ordered by a doctor when you left the hospital. The Plan denied your request. The Plan says rules for payment for routine vision care have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained through a provider in the Plan's routine vision provider network. We looked at the file and the Plan's rules. In this case, the items at issue were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) and lenses (V2784) provided on January 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene rearrangement testing (81340, 81342) provided on February 11, 2021.

You asked the Plan to pay for gene rearrangement testing. You say that this is supported by the records. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of gene rearrangement testing have not been met. Therefore, we decided that the Plan does not have to pay for gene rearrangement testing (81340, 81342) provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery (extraction of all remaining teeth).

You asked the Plan to pre-approve oral surgery. You say that the enrollee has multiple comorbidities and needs to have this surgery done in an outpatient setting. The Plan denied your request. The Plan says the denial of authorization for these services is correct.

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 Plan covers oral surgery when the services are medically necessary and reasonable. 

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 oral surgery. Our reviewer says that the enrollee does not meet the criteria for the requested services. Our physician reviewer found the documentation is insufficient to demonstrate that the requested outpatient oral surgery is medically reasonable and necessary for the enrollee. The diagnoses are dental caries, unspecified, and inflammatory conditions of the jaws. The teeth at issue are not identified and the records submitted do not contain imaging. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of oral surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve oral surgery (extraction of all remaining teeth).