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

We decided that the Plan does not have to pre-approve a second cervical spinal cord stimulator and implantation of electrodes 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 placement of a second stimulator 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 criteria not met for a second stimulator. There is no cervical trial of a stimulator. 

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 a second cervical spinal cord stimulator and implantation of electrodes for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an eye exam provided by on September 24, 2021.  

You asked the Plan to waive the copayment for the eye exam. You say that you feel that you should not be charged a copayment for a post-operative appointment. 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 $40 copayment for eye exams to diagnose and treat diseases and conditions of the eyes.   

You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Vision Care 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 eye exam provided by on September 24, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.

You asked the Plan to pre-approve Genvisc. You say that the requested Genvisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Synvisc/Synvisc One or Euflexxa.

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 Genvisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the Plan's required drug(s) 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 Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from November 23, 2020, to December 22, 2020. We also decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the pelvis provided on November 23, 2020.

You asked the Plan to waive the coinsurance and copayment for the radiation therapy services and the MRI. You say that you were not in the hospital for treatment and you feel that the charges are excessive. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 20% coinsurance for radiation therapy services at an outpatient hospital or freestanding radiological facility. 

Your contract with the Plan also clearly says that you must pay a $250 copayment for advanced imaging services at an outpatient hospital facility, including MRI's. 

You have been asked to pay $1887.72, which is 20% of the allowed amount for the radiation therapy services. You have also been asked to pay a $250 copayment for the MRI. The total for all services is $2137.72. The radiation therapy services and the MRI fall 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 coinsurance for radiation therapy services provided from November 23, 2020, to December 22, 2020. We also decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the pelvis provided on November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous spacer placement (C9752, 22899, C9753).  

You asked the Plan to pre-approve the interspinous spacer placement. You say that the services are medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.  

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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of procedure is considered investigational. More research is needed to show safety and efficacy. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (C9752, 22899, C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the medical documentation submitted with your appeal does not show that you have mobility limitations that significantly impairs your ability to participate in or more mobility-related activities.  

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you have a personal mobility deficit that impairs participation in activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the home. The provided records indicate that the scooter is requested to assist with activities such as grocery shopping. There is no documentation that the mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair.  

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and drug testing provided on June 28, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the office visit and drug testing. You say that you were misinformed by the Plan that you were an in-network provider and only a primary care physician (PCP) was needed. 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 you and the referring provider are both out-of-network. Therefore, we decided that the Plan does not have to pay for the office visit and drug testing provided on June 28, 2021, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin.

You asked the Plan to pre-approve Avastin. You say that the requested Avastin is medically necessary. The
Plan denied your request. The Plan says the enrollee must try and fail Zirabev 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 Avastin. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records
provided the enrollee has not tried and failed the required drug(s). There is no indication that the Plan's required
drug(s) 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 Avastin have not been met. Therefore, we decided that the Plan does not have to
pre-approve Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from August 24, 2021, to August 31, 2021.  

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you have already paid for an inpatient stay at another facility and this stay should not have been that long. 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 $310 per day for days 1-5 and $0 per day after day 5 for each inpatient stay.   

The record shows you were in the hospital from August 24, 2021, to August 31, 2021. Therefore, you have been asked to pay $310 per day for the first 5 days 1for the inpatient hospital services. The total for your stay is $1550 ($310 copayment x 5 days = $1550). Inpatient hospital services falls within the Inpatient Hospital Care 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 inpatient hospital services provided from August 24, 2021, to August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from January 26, 2022 onward.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found you were admitted to the hospital on January 20, 2022 with unspecified psychosis. Based on the provided records, it is not expected you will improve in a reasonable period of time beyond the dates in question, as you are not showing suicidal or homicidal ideation and have no auditory or visual hallucinations. You are compliant with care with no dangerousness to self or others. The services are not reasonable expected to improve your condition or be for the purpose of diagnosis. It does not appear that active treatment is taking place beyond the dates in question. The continued services are not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services from January 26, 2022 onward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) provided on August 12, 2021.

You asked the Plan to pay for the implant supported porcelain/ceramic crown. You say that you would like to use the 30% discount for the insertion of your crown. The Plan denied your request. The Plan says there is no coverage for implant supported porcelain/ceramic crown services. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on July 30, 2021.  

You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the differences in billing for the same injection. 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 20% coinsurance for Medicare Part B prescription drugs.   

You received a Medicare Part B drug on July 30, 2021. The total allowed amount is $6,373.19 and 20% of that is $1,262.14.   

You have been asked to pay the total coinsurance amount of $1,262.14 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection provided on July 30, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve the reinstatement of dialysis.

You asked the Plan to pre-approve the reinstatement of dialysis. You say that the requested reinstatement of
dialysis is medically necessary. The Plan denied your request. The Plan says that the requested reinstatement of
dialysis is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 the reinstatement of dialysis. Our
reviewer says that the requested reinstatement of dialysis is medically necessary. Our physician reviewer found
the record indicates that the enrollee has end stage renal disease. The record indicates a complicated medical
history including a stroke in 2010 and has been bed/wheelchair bound with aphasia, visual field loss, right
hemiplegia, and right facial droop. The record indicates that the enrollee was readmitted to a non-plan hospital
after being discharged from plan hospital where she was treated for urosepsis. Later the same day she was
readmitted to a non-plan hospital where dialysis was attempted but clinically not possible due to bradycardia
and hypotension.

The record indicates that the enrollee has renal failure. Dialysis is the standard of care treatment for renal
failure. The plan argues that the enrollee has an advanced directive. It is not the Independent Review Entity,
nor the plan's, role to use a medical necessity determination as a surrogate for interpreting the meaning and
intent of a legal document. This issue is between the providers and family, with input from the court if needed.

The record provided establish the medical necessity and reasonableness, as defined by Medicare rules, of the
requested service. The elements of the coverage criteria are satisfied. The requested service is recommended.

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 reinstatement of dialysis have been met. Therefore, we decided that the Plan
has to pre-approve the reinstatement of dialysis.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on August 20, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that you understand the charges for an X-ray but never saw a physician so disagree with the $45 copayment. 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 $45 copayment for urgently needed services provided by providers other than a primary care physician.   The record shows that you received urgently needed services on August 20, 2021. Therefore, you are responsible to pay the $45 copayment.   You have been asked to pay a $45 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on August 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that the services are medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.
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 skilled nursing services. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's physical
function is at or near her baseline and she can receive 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pre-approve skilled nursing visits.