Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the vascular ultrasound provided on July 14, 2021.  You asked the Plan to reduce the copayment for the ultrasound. You say that you were told you would only have to pay a $25 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $100 copayment for radiological diagnostic services.   You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the copayment for the vascular ultrasound provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit provided on February 16, 2021, by an OON provider.  You asked the Plan to pay for the home visit. You say that the provider should not be penalized for providing the medically necessary service. 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 a home visit provided on February 16, 2021, by an 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 you are appealing with supporting records. 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) 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 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: 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 26, 2021, to April 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that the services are 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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 26, 2021, to April 30, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pay for the office visit and physical therapy services provided out-of-area from March 4, 2021, through April 14, 2021.  You asked the Plan to pay for the office visit and physical therapy services. You say that you broke your ankle and leg on vacation and required medical services. You say that your reimbursements should be covered because you called the Plan prior to going on vacation to ask about your coverage. The Plan denied your request. The Plan says that you must receive care from a network provider.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records for review, nor did the Plan submit any documented attempts to obtain medical records. Your contract with the Plan covers urgent and emergent care anywhere in the world. Without medical records, we cannot determine whether the services you received while outside of the country were urgent or emergent in nature. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or medically justified according to Medicare rules or your contract with the Plan. Therefore, we decided that the Plan has to pay for the office visit and physical therapy services provided out-of-area from March 4, 2021, through April 14, 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH 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 at the current facility.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on July 8, 2021, by an OON provider.  You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and you were unaware the facility failed to get pre-authorization for the enrollee. 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. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 8, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and panoramic x-ray (D0330) provided on June 30, 2021.  You asked the Plan to pay for the dental services. You say that the dental office accepted your insurance card. You say that you should not be responsible for this bill. You also say that you would like some relief as this bill is a financial burden. The Plan denied your request. The Plan says that provider in this case is out of network. The Plan says that dental services received out of network are not covered.  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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and panoramic x-ray (D0330) provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that you need the scooter to move around. The Plan denied your request. The Plan says necessary services may be obtained 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 power scooter at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a power scooter to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an EKG provided on June 4, 2021.  You asked the Plan to waive the copayment for an EKG. You say that according to your Plan you should have one EKG covered a year and you should not be responsible for these charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $30 copayment for non-radiological diagnostic services.  You received an EKG on June 4, 2021. We cannot find anywhere in your contract with the Plan that says that EKG's are covered once per year. Therefore, you are responsible to pay the allowed amount of $13.04, which is less than the $30 copayment.    You have been asked to pay $13.04 for an EKG. An EKG falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an EKG provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional level of epidural steroid injections. You asked the Plan to pre-approve the requested services. You say that your pain is getting worse. The Plan denied your request. The Plan says it is not necessary to perform injections at more than 2 root levels during the same 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 you have chronic low back pain. You have an L5 compression fracture and severe spinal stenosis at the L4-L5 level. You also have a disc bulge with a annular fissure at the L5-S1 level. The request is for 2 levels of bilateral transforaminal epidural steroid injection. The Plan has agreed to pre-approve one level. Per coverage criteria, only one level bilaterally meets the criteria and is medically reasonable and necessary. Therefore, an additional level is not 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional level of epidural steroid injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  You asked the Plan to pre-approve Prolia. You say that the enrollee needs the injection for treatment of osteoporosis. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.  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 Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic Acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 21, 2021, to May 26, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were not in a private room, so you do not think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment per day for days 1-5, and a $0 copayment for additional days for inpatient hospital care.   Records show that you were in the hospital for 5 days.  You were charged a $395 copayment per day, for a total of $1975. This copayment applies regardless of the type of room you are in. 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 inpatient hospital services you received from May 21, 2021, to May 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on July 22, 2021.  You asked the Plan to waive the copayment for the EKG. You say that you went to have your annual wellness exam and were given an EKG.  You said that you should not have a copayment for this. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($13.87) is less than your copayment obligation, you are responsible for the full allowed amount.  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 $20 copayment for non-radiological diagnostic services.   You have been asked to pay a $20 copayment for the EKG. Your Evidence of Coverage explicitly states that if you get any testing during your annual wellness exam, separate cost sharing will apply for that testing. The EKG falls within the non-radiological diagnostic 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 copayment for the electrocardiogram (EKG) you had on July 22, 2021.