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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not show the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) and eyeglass deluxe frames (V2025) provided on April 14, 2021.
You asked the Plan to pay for progressive lenses and eyeglass deluxe frames. You say that rather than driving 20 or more miles for eyeglasses, you stopped at a local eye center. You found out they were not a Plan provider but since you had a prescription for the eyeglasses and you had not received glasses in 5 years, you decided to get them at this location. The Plan denied your request. The Plan says your benefit Plan does not cover out-of-network vision care services.
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 does not cover these services under any circumstance. We looked at the file and the Plan's rules. The EOC confirms that vision frames and lenses are not covered under your Plan. Based on this information, we decided that the Plan's rules for coverage of progressive lenses and eyeglass deluxe frames have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) and eyeglass deluxe frames (V2025) provided on April 14, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve continued use of intravenous immune globulin Privigen 500mg for
the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary for myasthenia gravis.
The Plan denied your request. The Plan says that long-term maintenance is not described and repeated
treatment regimens are not reported at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are medically reasonable and necessary. Our physician reviewer found the use of IV-Ig is
not the primary/first treatment modality used in this case. Prior treatments are well-documented. The enrollee's
neurologist clearly documents the medical need for the drug for this particular enrollee. Continued dosing of
IV-Ig is not prohibited by the LCD or the FDA-approved label.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to preapprove
continued use of intravenous immune globulin Privigen 500mg for the 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0427, A0425) provided on July 23, 2021.
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the ambulance transportation was not medically necessary, and the enrollee could have been transported in another vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The services at issue were billed as emergency ambulance services. Based on the records provided, the enrollee had been experiencing weakness and a constant dull pain in the left leg over the course of several days and had received previous hospital care for this issue. The enrollee denied having chest pains, shortness of breath, nausea, vomiting, or any injury. It does not appear that the ongoing pain was worse on the date in question or that any new symptoms presented. Although the enrollee likely needed medical care, the documented symptoms are not acute in nature and do not suggest that the enrollee would be in serious jeopardy without immediate medical attention.
There also does not appear to be any indication that the enrollee could not have been transported by other means. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services (A0427, A0425) provided on July 23, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continuation of admission to a skilled nursing facility (SNF).
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 daily skilled services are no longer required, and the continuation of skilled nursing facility services are not medically necessary.
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 continuation of services is medically reasonable and necessary. Our physician reviewer found you do qualify for ongoing SNF coverage. You do not have documented skilled nursing needs, but you do have documented skilled therapy needs. You are making progress with therapy. You have not yet reached the prior level of function, and the documentation does not yet show that you have reached a plateau a new lower level of function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your 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 continuation of admission to a skilled nursing facility (SNF).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the shaving of epidermal or dermal lesions (11305, 11306, 11311) provided from August 30, 2021, through October 7, 2021.
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible 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 $750 yearly deductible. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. You have been asked to pay $750 for the services provided as you had not previously met the deductible for this calendar year. 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 deductible for the shaving of epidermal or dermal lesions (11305, 11306, 11311) provided from August 30, 2021, through October 7, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 considered medically reasonable and necessary in this case. Our physician reviewer found that 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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe progressive lenses, tint photochromatic lens, anti-reflective coating and Hi Index lens provided on April 20, 2021.
You asked the Plan to pay for deluxe progressive lenses, tint photochromatic lens, anti-reflective coating and Hi Index lens. The Plan denied your request. The Plan says additional lens options such as deluxe progressive lenses, Hi Index, tinting, and anti-reflective coating are not covered by our Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that additional lens options such as deluxe progressive lenses, Hi Index, tinting, and anti-reflective coating are not covered by the Plan. Therefore, we decided that the Plan does not have to pay for deluxe progressive lenses, tint photochromatic lens, anti-reflective coating and Hi Index lens provided on April 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are not at an acute level of care and do not have daily skilled services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely provided in an alternate and lower intensity setting such in a skilled nursing facility with intermittent therapies. 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: Lab
Decision: Unfavorable

We decided that the Plan has to pay for the outpatient visit and lab services provided on November 25, 2020, through December 8, 2020.

You asked the Plan to pay for the outpatient visit and lab services. You say that you would like reconsideration because this service was ordered by your primary care physician. The Plan denied your request. The Plan says that the requested services were not provided in-network.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the outpatient visit and lab services by a contract provider. The file does not show that the Plan provided notice that the outpatient visit and lab services would not be covered. Under Medicare rules, this means the outpatient visit and lab services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the outpatient visit and lab services provided on November 25, 2020, through December 8, 2020.

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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are unlikely able to participate in an intensive therapy program of three hours of therapy a day at least 5 days 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 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 found to be medically reasonable and necessary for this enrollee. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia, congestive heart failure exacerbation, and NSTEMI. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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 been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.

You asked the Plan to pre-approve myocardial perfusion imaging. You say that myocardial perfusion imaging
is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of myocardial
perfusion imaging have not been met.

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 myocardial perfusion imaging. Our
reviewer says that myocardial perfusion imaging is not considered medically reasonable and necessary in this
case. Our physician reviewer found the record indicates that the enrollee was to undergo transcarotid
revascularization.

The record indicates that the enrollee is asymptomatic from a cardiac perspective, no other studies have been
performed, and a stress test was going to be performed. The record does not indicate the presence of one of the
enumerated conditions in the coverage criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that
the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient orthopedic office visit (99203, 20550, J1030)
provided on September 3, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you had no idea that they needed a pre-authorization
and assumed they would know something like that. You gave your insurance information and they did not tell
you that you would have to pay. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Nonemergent
services with non-contracted providers require prior authorization before services being rendered.
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 outpatient orthopedic office visit (99203,
20550, J1030) provided on September 3, 2020, by an out-of-network (OON) provider.