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

 
We decided that the Plan does not have to pay for the lab testing services provided on July 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing is not billed on the physician fee 
schedule. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
do not indicate the specimen at issue was obtained at an independent laboratory. If an independent lab bills for 
services, the place where the sample was taken is reported as the place of service. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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 of multiple unsuccessful weaning attempts. There is no documentation that the enrollee is capable of being weaned at this time. The enrollee does not require extensive or complex wound care management by skilled nursing of at least 6.5 hours per day. Additionally, the wound care does not require daily intervention by a physician. There is no documentation provided indicating medical necessity for 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 acute care hospital 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wrist manipulation under anesthesia for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental, investigational, and unproven.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology of complex regional pain syndrome of left upper limb. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for wrist manipulation under anesthesia is not medically reasonable or 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve wrist manipulation under anesthesia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kesimpta.
You asked the Plan to pre-approve Kesimpta. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 and does not represent an expense to a physician. Therefore, we decided that the Plan does not have to pre-approve Kesimpta.
Benefits for Kesimpta 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: 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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 documentation does not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis, on an inpatient basis, in a skilled nursing facility setting. You may benefit from skilled therapy services, but these can be provided at a lower level of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two clinical crown lengthenings (D4249 x2).
You asked the Plan to pre-approve the clinical crown lengthenings. You say that you need these services to be provided to you because you mouth is in bad shape. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve two clinical crown lengthenings (D4249 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary, and the enrollee will 
not benefit from any lower level of care. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. The Plan states the enrollee can safely receive the services they need in other 
settings, for example: a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation does not 
support that they would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services fifteen 
(15) hours a week, under the supervision of a physician with at least three (3) visits weekly to regain or 
maintain his/her functional status. The enrollee can receive further services at a lower level of 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails (11720) and the trimming of 
dystrophic nails (G0127) provided on August 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement of nails and the trimming of dystrophic nails. You say that 
authorization could not be obtained due to the patient misleading you with the incorrect insurance information. 
The Plan denied your request. The Plan says This provider is not a network provider with The Plan. The Plan 
also says that they have also determined that these services are not urgent or emergent, nor were they 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 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 debridement of nails (11720) and the trimming of 
dystrophic nails (G0127) provided on August 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder, elbow, wrist hand orthosis (L3960) provided on 
March 10, 2021. 
 
You asked the Plan to pay for the orthosis. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the file does not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. Specifically, the 
record indicates that the ordering provider as referenced on the claim did not order the requested orthosis. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for shoulder, elbow, wrist hand orthosis (L3960) 
provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric admission.
You asked the Plan to pre-approve the inpatient psychiatric admission. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient psychiatric admission. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of March 3, 2022 forward. This enrollee was not shown to be a danger to herself or others. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment with encouragement. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors or any treatment required for acute threats of safety. 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 inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on September 9, 
2021, and September 23, 2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were told there was no 
charge for the standard lens. 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 $225 
copayment per day for outpatient hospital surgery.  
 
The records show you had cataract surgery on September 9, 2021, and September 23, 2021. You have been 
asked to pay a $225 copayment per day for each cataract surgery. Cataract surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cataract surgery provided on September 9, 
2021, and September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for 1npatient hospital services provided from June 7, 2021, to June 11, 2021. We also decided that the Plan does not have to waive the copayment for ambulance transportation services provided on June 25, 2021. We also decided that the Plan does not have to waive the copayment for laparoscopic cholecystectomy (gallbladder removal) surgery performed on June 26, 2021.
You asked the Plan to waive the copayments for the inpatient hospital services, ambulance transportation, and gallbladder surgery. You say that you have bills from two separate stays and you feel that they should be treated as one. 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 $305 per day for days 1-5 and $0 per day after day 5 for each inpatient stay. Your contract with the Plan clearly says that you must pay a $225 copayment for each one-way ambulance trip. Your contract with the Plan clearly says that you must pay a $300 copayment for surgery services. The file shows that you were a hospital inpatient from June 7, 2021, to June 11, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $305 per day for the first 4 days of inpatient hospital services. The total for the stay is $1,220. The inpatient hospital services fall within the Inpatient Hospital Care benefit category. You have also been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. You have also been asked to pay a $300 copayment for the gallbladder surgery. The gallbladder surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 1npatient hospital services provided from June 7, 2021, to June 11, 2021. We also decided that the Plan does not have to waive the copayment for ambulance transportation services provided on June 25, 2021. We also decided that the Plan does not have to waive the copayment for laparoscopic cholecystectomy (gallbladder removal) surgery performed on June 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 21, 2021. 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim billed a place of service as an independent laboratory. The 
records provided do not show that the specimen was obtained at an independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a driving evaluation. 
 
You asked the Plan to pre-approve driving evaluation. You say that the behaviors that need to be evaluation 
would not be recognized by a driving instructor trained by the Department of Motor Vehicles (DMV). You also 
say that these services are necessary for you to be able to return to normal activities. The Plan denied your 
request. The Plan says driving evaluation is not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse evaluations 
performed solely to assess a beneficiary's ability to drive a vehicle.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of driving evaluation have not been met. Specifically, the file shows that the services are being 
requested to evaluation the enrollee's ability to drive a car. Therefore, we decided that the Plan does not have to 
pre-approve a driving evaluation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not have any stated contraindications to the preferred products.
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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary. The Plan requires a trial of Orthovisc, Synvisc or Synvisc-One before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Durolane. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ankle foot orthosis provided on April 23, 2021.
You asked the Plan to waive the coinsurance for an ankle foot orthosis. You say that the device does not fit nor work properly. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 10% coinsurance for prosthetic devices and related supplies. The enrollee received an ankle foot orthosis on April 23, 2021. The total allowed amount is $806.28 and 10% of that is $80.63.
The enrollee has been asked to pay the total coinsurance amount of $80.63 for an ankle foot orthosis. An ankle foot orthosis falls within the prosthetic devices and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an ankle foot orthosis provided on April 23, 2021.