Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chest x-ray, an ultrasound of the right wrist, and needle aspiration of the nodule to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a chest x-ray, an ultrasound of the right wrist, and needle aspiration of the nodule to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a chest x-ray, an ultrasound of the right wrist, and needle aspiration of the nodule to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the medical services rendered by the out-of-network (OON) provider on April 13, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of network provider, without prior authorization or a primary care physician (PCP) referral.
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. Additionally, a Point of Service benefit is offered to enrollees to receive care from an out-of-network provider. The Plan contract indicates that there is a Point of Service benefit offered to enrollees to receive care from an out of network provider. The Plan contract, states that a referral is not required when services are provided by an out-of-network provider under the Point of Service option. The contract additionally indicates that services not covered by an out-of-network provider will require a referral and some services provided require an authorization as well. However, the Evidence of Coverage (EOC) contract does not clearly disclose what services are covered by the Point of Service Benefit; nor which services require prior authorization; hence, the member would not be able to decipher which services would require a referral or prior authorization if an out-of-network provider is utilized. As such, we find that the denial issued for a lack of a referral or prior authorization is not supported. Therefore, we decided that the Plan has to pay for the medical services rendered by the out-of-network (OON) provider on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator in AVAPS mode.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the ventilator settings ordered for this ventilator could be provided with other devices.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found there is a diagnosis of chronic obstructive pulmonary disease, although pulmonary function tests are not provided. You were recently hospitalized with acute hypercarbic respiratory failure. There is no evidence of BiPAP failure when stable at home. Medicare does not cover a home ventilator when used as BiPAP.
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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator in AVAPS mode.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet joint procedures for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the pain appears to be associated with radiculopathy. The enrollee did not have the proper relief from the first injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint procedures for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided to the enrollee on January 16, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported.

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 99291 is "critical care visit of 30-74 minutes." 

We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document the time spent providing this service. This is necessary as CPT 99291 is a time-based code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.

Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided to the enrollee on January 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MAKOplasty with custom implant for the enrollee.

You asked the Plan to pre-approve these services. You say that the pain is affecting the member's home life. The Plan denied your request. The Plan says that there is no documentation that the enrollee's condition cannot be managed with conventional total hip arthroplasty.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Makoplasty with custom implant and computer assisted total hip surgery has not been shown to be more effective and better than conventional open total hip surgery. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve MAKOplasty with custom implant for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on September 28, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 remains not supported

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 15, 2021, to April 13, 2021.

You asked the Plan to pay for the SNF services. You say that you believe the continued SNF services should be covered. The Plan denied your request. The Plan says continued SNF care was not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that the enrollee had no identifiable skilled nursing or skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. This enrollee did 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 15, 2021, to April 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan (74177) provided March 22, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you were not provided with materials showing there was a $275 copayment. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 $275 copayment for diagnostic radiology. 

You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the diagnostic radiology 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 a Computed Tomography (CT) scan (74177) provided March 22, 2021.
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 the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says daily skilled services are no longer required.

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
daily skilled services are not necessary. Our physician reviewer found you do 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 after the last covered date. The
documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing
SNF need. Your functional level does 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 in a SNF after the last covered date. You do not require skilled nursing or skilled therapy services (or
a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the
necessary services on an inpatient basis, in a skilled nursing facility setting after 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 admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on April 22, 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care. The Plan denied your request. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member needs a higher level of rehab to get
home and care for himself. The Plan denied your request. The Plan says that the enrollee can safely receive the
services he needs 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for respiratory failure and a fall after missing a scheduled dialysis session. The
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's
condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the patient is unsafe to return home alone and has no support at home. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs at an alternate level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve an Iluvien intravitreal implant.

You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy must be tried.

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 implant. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found it is documented that you have worsening persistent macular edema despite Ozurdex injections. The documentation supports that a trial of a generic intravitreal-administered steroid has failed. 

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 implant have been met. Therefore, we decided that the Plan has to pre-approve an Iluvien intravitreal implant.

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 pay for physician services provided to the enrollee on March 8, 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 enrollee did not have prior authorization for 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 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 physician services provided to the enrollee on March 8, 2021.