Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).

You asked the Plan to pre-approve the additional transportation. You say that your only income is social security and you have multiple appointments to attend. The Plan denied your request. The Plan says you have used twenty-seven (27) one-way trips this year (2021) and have five (5) one-way trips available. The Plan also says that additional trips in excess of thirty-two (32) one-way trips are non-covered by the health plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty-two one-way or return trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) therapeutic exercises (97110) and mechanical traction (97012) provided on February 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that the medical records provided will show proof of medical necessity. 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. Non-emergent 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 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. 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 chiropractic manipulative treatment (98941) therapeutic exercises (97110) and mechanical traction (97012) provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during the claviculectomy provided on February 10, 2021.

You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not eligible for payment.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services during the claviculectomy provided on February 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323 x 6).

You asked the Plan to pre-approve Euflexxa injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Monovisc and Orthovisc.

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 Euflexxa injections. Our reviewer says that Euflexxa injections are not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred drugs, Monovisc and Orthovisc. The reviewer found that the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred drugs. Therefore, the reviewer found that the step therapy criteria has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa injections have not been met. Specifically, the file shows that the enrollee has not tried and failed the Plan's preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (J7323 x 6).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, hip, unilateral (73502) set-up portable x-ray equipment (Q0092) transportation of portable X-ray equipment and personnel to home or nursing home (R0070) provided on April 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the portable x-ray services. You say that the diagnostic radiology procedures that you are billing for does not require authorization. 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. Non-emergent 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 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. 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 radiologic examination, hip, unilateral (73502) set-up portable x-ray equipment (Q0092) transportation of portable X-ray equipment and personnel to home or nursing home (R0070) provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for gammaglobulin (immunoglobulin) testing (82784) provided on May 7, 2021.

You asked the Plan to pay for gammaglobulin (immunoglobulin) testing. You say that this is supported by the records and was ordered by the physician. The Plan denied your request. The Plan says that the billed diagnoses do not support immune gamma-globulin administration.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that the billed diagnoses do not support immune gamma-globulin administration, but the service at issue is not immune gamma-globulin administration. The Plan has not provided any information to support the denial of gammaglobulin (immunoglobulin) testing. Therefore, we decided that the Plan has to pay for gammaglobulin (immunoglobulin) testing (82784) provided on May 7, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on April 8, 2021.

You asked the Plan to waive the deductible for an office visit. You say that this was your annual wellness exam
and you should not be responsible to pay 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. Your
contract with the Plan says that there is a $390 deductible which applies to physician/practitioner services,
including doctor's office visits. Your contract with the Plan also states that annual wellness exams are covered
once every 12 months.

You had an office visit on April 8, 2021. The record shows that you received an annual wellness exam less than
12 months prior. Annual wellness exams are only covered once every 12 months. Therefore, the visit you
received on April 8, 2021, cannot qualify as an annual wellness exam and you are responsible to pay your share
of the cost-sharing charges. The record shows that you had paid $168.86 toward the $390 deductible prior to
receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $221.14.

The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $390 deductible which applies to physician/practitioner services,
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an
office visit was received on April 8, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for an office visit provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the cardiology visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the cardiology visit to be provided by an out-of-network (OON) provider.. You say that you would like reconsideration because this request is urgent and you have seen multiple in-network providers. You also say that seeing another in-network provider who will not be able to help will just be a waste of time. The Plan denied your request. The Plan says that there are in-network providers available who can render this service.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any evidence that the suggested providers are able to render the necessary care. The Plan has not forwarded medical records. The member has addressed that they have been seen by multiple in-network providers and have been dissatisfied with their care. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve the cardiology visit to be provided by an out-of-network (OON) provider.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home health physical therapy visits.

You asked the Plan to pre-approve 7 additional home health physical therapy visits. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated with a home exercise program.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked 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 7 additional home health physical therapy visits. Our reviewer says that the requested home health visits are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee is functioning at a level that supports a lower level of 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 7 additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home health physical therapy visits.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 receiving appropriate care at the present acute care hospital. 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. 

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: Favorable

We decided that the Plan has to pay for the revision of external ears provided on April 7, 2021.

You asked the Plan to pay for the revision of external ears. You say that the revision of external ears provided
on April 7, 2021 was medically necessary. The Plan denied your request. The Plan says that the revision of
external ears provided on April 7, 2021 was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the revision of external ears. Our reviewer
says that the revision of external ears provided on April 7, 2021 was medically necessary. Our physician
reviewer found the record indicates that the enrollee has bilateral ear burn scar contractures. The burn
contracture is impairing the ability to wear a mask. The contracture is the result of trauma. The elements of the
coverage criteria are satisfied. The requested service is 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 the revision of external ears have been met. Therefore, we decided that the Plan
has to pay for the revision of external ears provided on April 7, 2021.

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 the enrollee's overall needs and condition can be met at an LTACH for the best level of care for extended recovery and vent weaning needs. The Plan denied your request. The Plan says the requested service 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 short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The enrollee is presently receiving medically necessary services in the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate (and endorsed by the health plan) until the enrollee is stable to transfer to a lower level of 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and full leg garments (E0667).

You asked the Plan to pre-approve a pneumatic compression device and garments. You say that you are requesting an appeal regarding the denial of coverage for the Flexitouch pneumatic compression pump prescribed. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and full leg garments (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you do not feel comfortable leaving the hospital the same day of your surgery. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because this procedure can be performed at a lower level of care and if you experience peri- or post-operative complications reconsideration for inpatient level of care can be given.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this case. Our physician reviewer found you do not have documented cardiac, pulmonary, or kidney risk factors or any other condition that would suggest a need for inpatient hospital services spanning at least 2 midnights. Recent notes do not suggest any special circumstances given that you are a low-risk patient and this is a low-risk ambulatory procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
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 require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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. 

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.