Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.  You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is affecting her daily activities. The Plan denied your request. The Plan says it is not medically reasonable and necessary to perform injections at more than 2 levels in one session.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical 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 pre-approve the requested services. Our physician reviewer found that the enrollee has low back pain with radiculopathy. There was reduced range of motion in flexion, extension, bilateral rotation, and lateral bending.  Pain increased in flexion, extension, and bilateral rotation. Bilateral transforaminal epidural injections were requested. Per coverage criteria, it is not considered medically reasonable and necessary to perform transforaminal epidural steroid injections at more than two nerve root levels during the same session. The Plan approved bilateral injections at one level. The review has determined that the requested additional level for treatment is not indicated for the enrollee's 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) 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 the plan has no contractual obligation to cover services that are not reasonable and
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented
skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is not yet
documented to have reached a plateau in function. Daily skilled services are required to establish a
maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee's care needs
cannot, as a practical matter, currently be provided at a lower level of care (ex. home, AL, LTC).
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 a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with COVID-19 infection and urinary tract infection. From a nursing perspective, the enrollee received oral medications.  The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a maximal assist level with functional mobility and with activities of daily living.  There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the cost sharing for nurse practitioner services you received on  May 13, 2021.  You asked the Plan to waive the cost sharing for the nurse practitioner services. You say that the provider is billing you directly for these services and they should be covered. The Plan denied your request. The Plan says that you were charged this coinsurance correctly.  The Plan says that your Medicaid plan should be responsible for paying this coinsurance.  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 enrollees must pay a $0 copayment for physician/practitioner services.   The Plan says you must pay 20% coinsurance for the nurse practitioner services. We do not agree.  Your Evidence of Coverage explicitly states that you pay nothing for physician/practitioner services.  There is nothing in your Evidence of Coverage that discusses coinsurance or a deductible for these services.  Furthermore, the Plan made reference in its case file to a "Benefit Grid" that lists this coinsurance obligation.  The Plan has failed to supply that Benefit Grid to us.  In addition, there is no evidence that the Benefit Grid is made available to enrollees.  Plans are required to disclose all cost sharing obligations to enrollees, and we have no evidence that is the case here. We understand that you may have Medicaid coverage.  However, the burden still lies with the Plan to prove that its assessment of cost sharing is correct. Based on the Plan contract, you cannot be asked to pay more than a $0 copayment for the nurse practitioner services. Therefore, we decided that the Plan has to waive the cost sharing for nurse practitioner services you received on  May 13, 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 copayment for the urgent care visit you had on March 29, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that the doctor at the urgent care center was rude and did not help you. 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 $40 copayment for urgent care services.   You have been asked to pay a $40 copayment for the urgent care visit. This copayment applies regardless of your satisfaction with the services received. 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 urgent care visit you had on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on June 28, 2021.  You asked the Plan to pay for code A0429. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.   We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on June 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 drug testing provided on June 23, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a duplex scan extremity test provided on August 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for extremity test. You say that this treatment was requested by your treating physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 a duplex scan extremity test provided on August 8, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee has limited mobility and needs therapy. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a periodontal cleaning (D4910) provided on August 18, 2021.  You asked the Plan to pay for a periodontal cleaning. You say that your dentist advised you that due to your contract with your Plan you can only get a periodontal cleaning. You also say that you called the Plan after your visit and was told that the provider gave you incorrect information. The Plan denied your request. The Plan says periodontal maintenance cleaning is not a covered service under your Plan.  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 a periodontal cleaning (D4910) provided on August 18, 2021.   Your complaint about the incorrect information your provider gave you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with C. difficile infection and urinary tract infection. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a modified independent to independent level with functional mobility including gait to 70 feet.  There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is ready for discharge from the hospital.  The member does not require skilled nursing and/or skilled therapy services on a daily basis.  He is medically stable and can receive further rehab services at a lower level of care.  Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube.  He is medically stable without any acute exacerbations of chronic medical problems.  His physical function is at or near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit.  You asked the Plan to pre-approve Retacrit. You say that the additional information and lab work supports the need for the requested drug. The Plan denied your request. The Plan says the documentation provided shows the results of a bone marrow test did not support a confirmed diagnosis of Myelodysplastic Syndrome. Additionally, the documentation did not show ferritin level greater than or equal to 100 mcg/L or serum transferrin saturation greater than or equal to 20% obtained within the last three months. Based on the current clinical information, the enrollee does not meet criteria for use of this requested medication 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 Retacrit. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of Pancytopenia. The enrollee's hemoglobin levels are less than 10. She has adequate iron levels anderythropoietin levels less than 500. The enrollee's Myelodysplastic Syndrome mutational analysis was positive, but her marrow was not definitive for Myelodysplastic Syndrome. Medical standards allow use of Retacrit for patients with Myelodysplastic Syndrome. The use of Retacrit for this patient is not considered medically reasonable and 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.