Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for IRF admission and services provided from August 17, 2021,
to September 1, 2021.
You asked the Plan to pay for IRF care. The Plan denied your request. The Plan says an IRF admission was 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 pay for 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 based on the medical records provided that the complexity of the enrollee's nursing,
medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The enrollee's medical conditions were overall stable though with uncontrolled
hypertension that was managed with outpatient medications (Coreg and hydralazine) and with no issues that
required a physician's evaluation three or more times per week. The enrollee did require physical therapy and
occupational therapy services but based on the medical records provided the enrollee did not require an
intensive inpatient rehabilitation therapy program. Based on the medical records provided there was no
documentation that the enrollee required the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility. Care at the skilled nursing facility level appeared to have been appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pay for IRF admission and services provided from August 17, 2021, to September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monovisc.  You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the step therapy requirements have not been met.  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 Monovisc. Our reviewer says that Monovisc is not medically reasonable and necessary in this case. Our physician reviewer found that the provided records did not show evidence of the enrollee having tried and failed Orthovisc, Synvisc or Synvisc One. The preferred agents would not likely be less effective or likely have adverse effects for the enrollee, as they are clinically equivalent in comparative studies.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 6 units of this
code, exceeding the MUE. 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 pay for the laboratory services
rendered on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure would provide significant clinical and
quality of life benefits. The Plan denied your request. The Plan says the denial of authorization for Vertiflex is
correct, because studies have not proven that Vertiflex is helpful for treatment of the enrollee's condition.
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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental, more research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex procedure.
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 inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary care can safely be provided in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 LTACH service are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of LTACH services.
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 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Cuvitru.  You asked the Plan to pre-approve Cuvitru. The Plan denied your request. The Plan says the step therapy requirements have not been met.  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 Cuvitru. Our reviewer says that Cuvitru is not medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not show that the enrollee had a trial and failure of Flebogamma DIF, Gammagard Liquid, Gammagard S-D(IgA < 1 mcg/mL), Gammagard S/D, Gammaked, Gamunex-C, Hizentra, Octagam, Privigen, or Xembify to justify this request. The above preferred drugs would not likely be less effective or have adverse effects for the enrollee, as they are clinically equivalent products with similar effectiveness and safety data.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cuvitru have not been met. Therefore, we decided that the Plan does not have to pre-approve Cuvitru.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided at the in-network
benefit level by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you disagree with the denial of in-network
benefits. The Plan denied your request. The Plan says the denial of authorization for in-network benefits is
correct, because this provider is out-of-network with the Plan and you may choose to visit this provider using
your Point-of-Service (POS) benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that enrollees may choose to receive care from out-of-network providers using the Plan's Point-of-
Service (POS) benefits.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services at the in-network benefit levels. You may choose to receive
services from this provider using the Plan's Point-of-Service (POS) benefits. Therefore, we decided that the
Plan does not have to pre-approve cardiology services to be provided at the in-network benefit level by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous passive motion device provided on October 21, 2021.  You asked the Plan to pre-approve a continuous passive motion device for shoulder surgery. You say that this device replaced the need for shoulder therapy after surgery. The Plan denied your request. The Plan says Medicare does not cover this device for any surgery other than knee surgery and then only for a limited time.  The Plan must follow Medicare rules. The rules say that continuous passive motion devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. You did not have prior authorization for this equipment. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion device provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 28,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit to find
out the results of a colonoscopy. 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 $40
copayment for specialist visits.
You had a specialist visit on October 28, 2021. Follow-up visits are subject to cost-sharing charges. Therefore,
you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 16, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on April 16, 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 you meet criteria for IRF admission. The Plan denied your request. The Plan says the criteria for admission to the IRF setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your ongoing skilled therapy and nursing needs as well as ongoing antibiotics can be provided at a lower level of care. There is no indication you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies or intensive therapy. You would benefit sufficiently from a lower level of care instead.  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 waive the copayment for an ultrasound study provided on August 11,
2021.
You asked the Plan to waive the copayment for an ultrasound study. You say that the doctor wanted to rule out
a blood clot. 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 $110
copayment for radiological diagnostic services.
You have been asked to pay the allowed amount of $107.75, which is less than the $110 copayment for an
ultrasound study. An ultrasound study 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 ultrasound study provided on August 11,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
October 14, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not satisfied with the
first provider's treatment, and you do not feel they should have been paid for the visit. The Plan denied your
request. The Plan says this service exceeds the frequency limitation in 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, comprehensive oral evaluation
(D0150) is limited to one procedure every three plan years. The record shows that you received a
comprehensive oral evaluation (D0150) on October 5, 2021, and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and
interpretation (D0367) provided on September 20, 2021.
You asked the Plan to pay for the dental service. You say that you were advised you may have a dental
infection affecting your sinuses. You also say that this service was necessary. The Plan denied your request.
The Plan says cone beam CT is not listed as a covered service.
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 cone beam CT is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam
computed tomography (CT) capture and interpretation (D0367) provided on September 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on October 27, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on October 27, 2021, by
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September
9, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that there was no exam done, just
the coronavirus test. 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 $45
copayment for each visit to other providers for urgently needed services.
You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls 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 an urgent
care visit provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
You asked the Plan to pre-approve the requested services. You say that you are in extreme pain. The Plan
denied your request. The Plan says you are not taking part in an exercise program.
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 with radiation to your lower extremities. According to the
submitted records, you have not participated in an active rehabilitation exercise program or home exercise
program. The review has determined that you do not meet the coverage criteria for the requested injections.
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 lumbar epidural steroid injections.