Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for outpatient mental health care provided on March 15, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the provider is not an eligible Medicare provider and there is no physician referral or prior authorization.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. The enrollee was not referred and did not have prior authorization. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 31, 2021.

You asked the Plan to pay for the laboratory services. You say that you would lie the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The documentation does not support that the services were not provided for screening purposes. This means that the laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 x-ray services provided on April 7, 2021 by an
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study you had at an outpatient hospital facility on March 11, 2021.
You asked the Plan to waive the copayment for the sleep study. You say that you already paid $60 for this service and do not feel you should have to pay the balance of $90. 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 $150 copayment for diagnostic procedures and tests. You have been asked to pay a $150 copayment for the sleep study. The sleep study falls within the diagnostic procedures and tests 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 the sleep study you had at an outpatient hospital facility on March 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says SNF care is no longer 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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need beyond the last covered date. The enrollee's functional level did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF beyond the last covered date. The enrollee did not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF beyond the last covered date. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says there is no medical necessity to authorize an out-of-network provider when care can be provided in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation injections.
You asked the Plan to pre-approve radiofrequency ablation injections. You say that you feel these services should be covered. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. Review of the file shows that you received radiofrequency ablation services in October 2020 and March 2021. This means you have had two sessions within 12 months. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation injections have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says outpatient care would be more appropriate.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, the enrollee does not meet the criteria for continued inpatient mental health treatment, as she was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations, delusions and was cooperative/compliant with treatment while not showing any acute threats the safety. It did not appear that active treatment was taking place beyond September 14, 2021. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. The health plan's denial of continued inpatient psychiatric services is appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve blocks with fluoroscopic guidance provided on January 11, 2021.

You asked the Plan to pay for the genicular nerve blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that genicular nerve blocks are only covered for certain indications. 

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 genicular nerve blocks. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has chronic knee pain following a fall. The enrollee has tried Toradol, viscosupplementation times three, as well as steroid intra-articular injection. The MRI is five years old and at that time, there was a suggestion of a menicus tear. The services rendered are considered experimental/investigational. It is the subject of ongoing clinical trials. Therefore, the enrollee did not meet criteria for the services rendered. 

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 genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve blocks with fluoroscopic guidance provided on January 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 32 physical therapy visits.
You asked the Plan to pre-approve the 32 physical therapy visits. You say that the records provided support the need for the number of physical therapy visits being requested. The Plan denied your request. The Plan says the criteria for coverage of physical therapy have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 32 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The enrollee is independent with a home exercise program. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are 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 32 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 32 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and additional weaning is required along with other acute care services for the short term which can be safely administered at the current facility. The enrollee does not require LTACH services that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered and the current facility. Therefore, this request for LTACH services will be considered not medically necessary as transfer would not likely provide a clinical advantage. Transfer may be considered when treatment has completed.
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services you received at an acute inpatient rehabilitation hospital from March 19, 2021, to March 29, 2021.
You asked the Plan to waive the copayment for the acute inpatient rehabilitation hospital services. You say that you were in another hospital from March 16, 2021, to March 19, 2021, so you should not have to pay another copayment. The Plan denied your request. The Plan says you were in an acute care hospital from March 16, 2021, to March 19, 2021. You were discharged from the acute care hospital and transferred to an inpatient rehabilitation hospital. The Plan states the copayment for the first hospital stay has been waived and you are only responsible for the copayment for your stay at the inpatient rehabilitation hospital.
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 $325 copayment per day for days 1-5 for inpatient rehabilitation care.
You have been asked to pay a $325 copayment per day for days 1-5 for the acute inpatient rehabilitation hospital services. 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 services you received at an acute inpatient rehabilitation hospital from March 19, 2021, to March 29, 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 medical records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
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
was admitted for congestive heart failure and bilateral lower extremity cellulitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. 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 a 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane viscosupplement injections.
You asked the Plan to pre-approve the Durolane injections. You say that the use of this drug is medically necessary. The Plan denied your request. The Plan says there is no documented reason that the preferred viscosupplements cannot be used.
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 the Durolane injections. Our reviewer says that the requested agent is not considered medically reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Durolane is not approved as step criteria have 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 the Durolane injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane viscosupplement injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amounts for the limited oral evaluation and the
intraoral - periapical first radiographic image services and to pay for the re-cement or re-bond crown services
received on December 30, 2020.
You asked the Plan to waive the cost share amounts for the limited oral evaluation and the intraoral - periapical first radiographic image services and to pay for the re-cement or re-bond crown services. You say that you
urgently needed these services. The Plan denied your request. The Plan says the services were processed
correctly per your plan benefits.
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 any amount not covered for out of network dental services. You have been asked to pay any amount not covered for the limited oral evaluation and the intraoral - periapical first radiographic image services and to pay for the re-cement or re-bond crown services. The limited oral evaluation and the intraoral - periapical first radiographic image services and to pay for the re-cement or re-bond crown services falls within the out of network dental services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share amounts for the limited oral evaluation and the intraoral - periapical first radiographic image services and to pay for the re-cement or re-bond crown services received on December 30, 2020.