Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal injection provided on October 4, 2021.
You asked the Plan to pay for the spinal injection. You say that the treatment rendered is accepted as medically necessary for the enrollee's condition. The Plan denied your request. The Plan says no records were submitted to support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. No medical records were submitted for review. As such, it cannot be confirmed that coverage criteria are met. Based on this information, we decided that Medicare rules for coverage of the spinal injection have not been met. Therefore, we decided that the Plan does not have to pay for the spinal injection provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on October 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON lab testing. You say that this should be covered as it was ordered by the treating provider. The Plan denied your request. The Plan says these services were ordered by an OON provider and performed by an OON lab. These are not shown to be emergency/urgently needed services. As such, authorization would be required for OON coverage.
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, nor is the ordering provider. 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 the laboratory testing provided on October 18, 2021, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 19, 2021, to August 24, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered as they were covid-19 related. The Plan denied your request. The Plan says the cost-sharing applied correctly and there are no guidelines that state cost-sharing for covid-19 hospitalizations will be covered in full, the regular cost-sharing is still applicable based on the services you receive.
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 $300 copayment per day for days 1-5 of Inpatient hospital care.
You have been asked to pay a $1,500 copayment for five days of inpatient hospital care ($300 x 5 = $1,500). 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 care provided from August 19, 2021, to August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 does not meet criteria.
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 enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level. 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria.
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 you are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require 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: 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 an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 enrollee does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services, or a combination of these services, on a daily 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 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 appropriate level of care is an
LTACH. The Plan denied your request. The Plan says there is no clinical advantage of LTACH over an acute
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 that there is no documentation provided indicating medical necessity for admission to
an LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at
the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no
services available at the LTACH that you require 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
your diagnosis and condition 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 25, 2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.
The Plan must follow Medicare rules. Medicare rules say that that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include a procedure report that clearly documents the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, in the record there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 25, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not tried and failed Durolane, Monovisc, or Synvisc-One.
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 Gel-One. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. The documentation does not support that the enrollee has tried and failed the required drugs. The documentation does not support that the plan's required drugs would likely be less effective or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy services provided from April 28, 2021, to June 1, 2021.
You asked the Plan to waive the copayment for the radiation therapy services. You say that the services should be covered, and the charges are incorrect. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $60 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $1,130 copayment for sixteen radiation therapy service visits ($60 x 19 = $1,140 - $10 credit = $1,130). Radiation therapy services 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 copayment for radiation therapy services provided from April 28, 2021, to June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show failure to improve after treatment ordered by the doctor.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has back pain for about a month. The record indicates that the pain is not radicular (leg pain related to brain injury in past and fibromyalgia). The record does not indicate the presence of red flag physical examination findings. The record does not indicate that the enrollee has tried and failed conservative measures including physical therapy. The record does not indicate the occurrence of acute injury. The record does not include a neurologic or mental status examination. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genetic testing.  You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says the requested testing 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 genetic testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there are no provided examination findings and symptoms associated with Ehlers Danlos syndrome, such as the vascular form of Ehlers-Danlos Syndrome which are required for genetic testing. The review has determined that the requested genetic testing in this case 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode that could be delivered by bilateral positive airway pressure (BiPAP) is not 
covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has chronic obstructive pulmonary disease (COPD) and was recently hospitalized. A venous blood gas 
suggested acute CO2 retention. 
However there is no arterial blood gas (ABG) documenting CO2 retention obtained while the enrollee is awake 
and stable. The record states the enrollee has severe COPD, but pulmonary function test results are not 
included. If the enrollee has chronic CO2 retention, she may benefit from BiPAP support during sleep. 
Medicare does not cover a home ventilator when used as BiPAP. There is no evidence of BiPAP failure. The 
enrollee does not have generalized neuromuscular disease or thoracic restrictive disease.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing exam (92653), an Electroencephalogram (95816), and a mental health care visit (96138) provided on September 3, 2021.
You asked the Plan to waive the copayment for the hearing exam, an Electroencephalogram, and a mental health care visit. You say that the services should be covered as you were not made aware of the copayments beforehand, and they would cause you financial hardship. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 Hearing services and Outpatient mental health care services and a $50 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $40 copayment for both the hearing exam and mental health care visit, and a $50 copayment for the Electroencephalogram. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a hearing exam (92653), an Electroencephalogram (95816), and a mental health care visit (96138) provided on September 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee was able to ambulate on her own without assistance prior to hospitalization and since being in the hospital needs therapy to regain mobility. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage. 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an epidural steroid injection (62320) provided on September 13, 2021.
You asked the Plan to pay for an epidural steroid injection. You say that this treatment is part of a pain management program. The Plan denied your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that in order for epidural steroid injections to be covered, the procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.
We looked at the file and Medicare rules. The percent pain relief achieved immediately post-injection is not documented in the submitted records. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pay for an epidural steroid injection (62320) provided on September 13, 2021.