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

We decided that the Plan does not have to pay for a physician visit provided on March 22, 2021 by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for physician visit. You say that you are appealing with supporting records. 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 the referring nursing facility is also out-of-network with the Plan.

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 physician visit provided on March 22, 2021 by
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics (PGx) testing provided on March 5,
2021, billed with codes 81291, 81335, 81408, and 81479.

You asked the Plan to pay for the PGx testing as billed. You say that this should be paid and full as all genes
are needed to be tested to give the necessary information. The Plan denied your request. The Plan says these
genes are tested in parallel and are considered part of a single panel. As such, one code should be reported for
the panel.
The Plan must follow Medicare rules. Medicare rules say that when genetic testing is done on more than one
gene at once, and the results of one gene testing do not affect the others, it is considered a parallel panel. This
must be reported with a single code.

The genes at issue were tested in parallel and were all tested for the same purpose. As such, reporting a code
for each gene tested is not appropriate. Therefore, we decided that the Plan does not have to pay for the
pharmacogenomics (PGx) testing provided on March 5, 2021, billed with codes 81291, 81335, 81408, and
81479.
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 setting is the appropriate level of care for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
admission to an IRF.

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 that 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.
Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your
request. The Plan says additional transportation trips are not a covered benefit under your Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.

We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers up to
50 one-way trips and additional transportation trips are not a covered benefit under your Plan. Based on this information, 
we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service is 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 subsequent nursing facility care provided on September 1, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-one.

You asked the Plan to pre-approve Synvisc-one. You say that the requested Synvisc-one is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc first.

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 Synvisc-one. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found this appeal considers the request for Synvisc-One for the treatment of primary osteoarthritis of the left knee. The enrollee has not trialed viscosupplemental treatments such as Orthovisc. Step therapy, as outlined by the Plan, requires that this be trialed first. The documentation does not outline contraindications or reasons this medication was not considered. Without the support of the documentation, Synvisc-One is not approved, as step therapy criteria has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-one.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910).

You asked the Plan to pre-approve periodontal maintenance. You say that this service is necessary. The Plan
denied your request. The Plan says this service is not covered by the Plan's dental benefit.

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 pre-approve
periodontal maintenance (D4910).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, the vaccine administration, and the blood draw provided on February 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit, the vaccine administration, and the blood draw. You say that the services were 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the office visit, the vaccine administration, and the blood draw provided on February 19, 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an
LTACH admission for direct daily physician assessment. The Plan denied your request. The Plan says the
enrollee does not meet criteria for an LTACH admission.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no evidence that the enrollee requires services that are not currently
available. As LTACHs and acute care hospitals (ACH) are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve aquatic therapy to be provided by the requested out-of-network provider. You say that you could not find a network provider who provides aquatic therapy. The Plan denied your request. The Plan says you do not indicate that you have an emergent or urgent medical condition or are in need of specialized service. There are in-network provider(s) within a reasonable distance from your location that can provide this service or item.
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 aquatic therapy to be provided by the requested out-of-network provider.
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 care is medically necessary. The Plan denied your request. The Plan says the request for IRF care is not medically necessary.

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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Favorable

We decided that the Plan has to pre-approve Infed.

You asked the Plan to pre-approve Infed. You say that the requested Infed is medically necessary. The Plan denied your request. The Plan says that the requested Infed is not medically necessary.

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 Infed. Our reviewer says that the requested Infed is medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is documentation that supports that the Infed is medically reasonable and necessary for the enrollee. The health plan has argued that the enrollee does not meet criteria for coverage of the Infed as his hemoglobin level was not less than 11 grams/dL and his mean corpuscular volume is not less than 95 fL. According to diagnostic criteria for iron deficiency anemia as detailed in Up to Date, with iron deficiency with mild anemia a hemoglobin level of 12 grams/dL can be seen as a normal mean corpuscular volume. The enrollee certainly has low iron saturation (19% and 12%) and ferritin levels (11 ng/mL); decreases in these laboratory parameters typically precede decreases in hemoglobin level and mean corpuscular volume as the anemia progresses. As stated in Up to Date: "a slight decline in hemoglobin (usually 1 to 2 g/dL) precedes microcytosis. Thus, in early iron deficiency and in many individuals in high-resource settings, the CBC may be relatively normal." Based on these criteria the enrollee does have laboratory findings consistent with iron deficiency anemia for which the Infed is Food and Drug Administration approved. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Infed have been met. Therefore, we decided that the Plan has to pre-approve Infed.

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 transthoracic echocardiography (93306) rendered by the out-of-network (OON) provider on May 17, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization or a 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, pre-approved care, and care received via the POS benefit with a referral from a primary care physician. A referral was not issued by the enrollee's primary care physician in this case. The Plan contract indicates that the enrollee must get a referral from their primary care physician prior to getting care from out-of-network providers via their POS benefit. If the enrollee does not get a referral, they will have to pay the full cost of any services they receive. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for transthoracic echocardiography (93306) rendered by the out-of-network (OON) provider on May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dulera.

You asked the Plan to pre-approve Dulera. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dulera.

Benefits for Dulera may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on May 13, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says due to the method of dispensing the requested drug, it has been approved under the enrollee's Part D plan.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.

Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you need the IRF care to gain strength and get back to your previous health before you were sent to the hospital. The Plan denied your request. The Plan says an IRF admission is not medically necessary.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.