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

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Eylea. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has a central retinal vein occlusion, left eye, with macular edema. The documentation does not support that the enrollee has tried and failed bevacizumab. The documentation does not support an indication that plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99212) provided on  
May 18, 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 service 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 $15 
copayment per visit for all covered services if performed by your primary care physician (PCP). 
 
You have been asked to pay a $15 copayment for the telehealth office visit 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 office visit (99212) provided on May 18, 2021.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
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. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 29, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a single power wheelchair (K0856) and accessories.
You asked the Plan to pre-approve a single power wheelchair and accessories. You say that the item is medically necessary. The Plan denied your request. The Plan says you are not capable of safely operating the PMD.
The Plan follows Medicare rules. Medicare rules say that the person must be capable of safely operating the PMD. 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 single power wheelchair and accessories. Our reviewer says that the item is not medically necessary. Our physician reviewer found you cannot safely operate a PMD. 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 single power wheelchair and accessories. have not been met. Therefore, we decided that the Plan does not have to pre-approve a single power wheelchair (K0856) 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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of your nursing, medical 
and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of gingival inflammation (D4346), gingival irrigation (D4921) and drugs or medicaments (D9630) provided on June 15, 2021.
You asked the Plan to pay for the scaling in presence of gingival inflammation (D4346), gingival irrigation (D4921) and drugs or medicaments (D9630). You say that you told them you did not want the deep cleaning because you could not afford it. You say that the codes should be changed so you don't have to pay out-of-pocket expenses and insurance can be billed. The Plan denied your request. The Plan says the services 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 the scaling in presence of gingival inflammation (D4346), gingival irrigation (D4921) and drugs or medicaments (D9630) provided on June 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued 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 no longer require 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 that your condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery you had at an ambulatory surgery center on July 7, 2021.

You asked the Plan to waive the copayment for the cataract surgery. You say that you were told that this surgery was 100% covered. You said that you are on a fixed income and cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery. 

You have been asked to pay a $250 copayment for the cataract surgery. 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 cataract surgery you had at an ambulatory surgery center on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty.
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and
necessary under specific circumstances.
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 kyphoplasty. Our reviewer says that the
services are not medically necessary. Our physician reviewer found criteria for kyphoplasty are not met. There
is no documented trial of bracing. Also, the magnetic resonance imaging (MRI) does not clearly show that this
is an acute fracture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve kyphoplasty.
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 you can barely walk, feed yourself and is in need of skilled nursing. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.
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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on May 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the x-rays. You say that the diagnostic radiology procedures you are billing for does not require authorization. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the x-rays provided on May 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 16, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on March 16, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current 
level of care. 
 
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 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. There are no 
required medical services identified that are available at the LTACH, that are not available at the current 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple options (K0862) and accessories.
You asked the Plan to pre-approve group 3 power wheelchair with multiple options and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary
The Plan follows Medicare rules. Medicare rules say that there must be medical need for a ventilator or for two power options: power tilt and power recline.
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 group 3 power wheelchair with multiple options and accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the member does not have medical need for the Multiple Power Options included with the requested K0862 group 3 power wheelchair with Multiple Power Options. To qualify for the requested group 3 power wheelchair with multiple power options, there must be medical need for a ventilator or for two power options: power tilt and power recline. The documentation does not show that the member is at "High Risk" for skin breakdown and the member is specifically noted to be at Moderate Risk for development of pressure ulcer, based on Braden Scale of 14. There is no self-catheterization or spasticity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of group 3 power wheelchair with multiple options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple options (K0862) and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation discharge services (99217) provided on June 7, 2021.
You asked the Plan to pay for the observation discharge services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no record of prior observation claims.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) We find that CPT code 99217 is not supported in the medical record. Specifically, the record does not include sufficient information to determine if this service was billed appropriately. The record does not include a claim for observation services or clinical information to determine if CPT code 99217 has been billed appropriately. Based on this information, we decided that Medicare rules for coverage of the observation discharge services have not been met. Therefore, we decided that the Plan does not have to pay for the observation discharge services (99217) provided on June 7, 2021
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the monitoring services (95938, G0453, 95861, and 95955) provided on January 14, 2021.
You asked the Plan to pay for the monitoring services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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. In this case, the Plan is denying payment stating the provider submitted a claim for payment with the incorrect place of service (POS). The Plan says that the provider used POS 21 for inpatient care incorrectly as the services were performed in an outpatient setting. However, we asked the Plan to provide the claim that was submitted and denied for payment to verify if the incorrect POS was billed. The Plan has not provided this information to verify if the Plan's denial of payment is appropriate. Therefore, we decided that the Plan has to pay for the monitoring services (95938, G0453, 95861, and 95955) provided on January 14, 2021.