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

 We decided that the Plan does not have to waive the coinsurance for Tocilizumab injections provided from May 25, 2021, to July 20, 2021.  You asked the Plan to waive the coinsurance for the Tocilizumab injections. You say that the services should be covered as the copayments are inconsistent. The Plan denied your request. The Plan says the coinsurance 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% coinsurance for Medicare Part B prescription drugs.     You have been asked to pay a 20% coinsurance for three Tocilizumab injections.    Dates of  Service Service Allowed Amount Standard Cost Member Liability May 25, 2021 Tocilizumab injection $3,965.04 20% $793.08 June 22, 2021 Tocilizumab injection $3.965.04 20% $793.08 July 20, 2021 Tocilizumab injection $4,204.32 20% $840.86  TOTAL:   $2,427.02  Tocilizumab injections fall 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 Tocilizumab injections provided from May 25, 2021, to July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Orthovisc.  You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says the enrollee has not failed at least 3 months of conservative therapy.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Orthovisc. Our physician reviewer found that the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. There are no difficulties with activities of daily living (ADLs). A steroid injection in the past did not provide significant relief. The enrollee has done physical therapy as well. The enrollee is taking ibuprofen with relief. While the documentation supports that the enrollee is symptomatic, with some pain and stiffness in his knees, there are no difficulties with ADLs. The documentation does not support that the enrollee has failed at least three months of conservative therapy. The enrollee has failed to respond to intra-articular corticosteroid injection therapy. The documentation does not support that Orthovisc is medically reasonable and necessary 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
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 IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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 while you may benefit from therapy, you do not need the necessary services at an IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extra heavy duty manual wheelchair (K0007).  You asked the Plan to pay for the extra heavy duty manual wheelchair.. You say that you would like reconsideration because the requested wheelchair is medically necessary. The Plan denied your request. The Plan says the records do not show that the member meets the minimum weight requirement.  The Plan must follow Medicare rules. Medicare rules say that an extra heavy duty wheelchair (K0007) is covered if the beneficiary weighs more than 300 pounds.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the extra heavy duty manual wheelchair. have not been met. Specifically, the documentation submitted does not support that the member meets the minimum weight requirement of 300 pounds. Therefore, we decided that the Plan does not have to pay for the extra heavy duty manual wheelchair (K0007).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continued inpatient mental health services to be provided after February 9, 2022.  You asked the Plan to pre-approve the continued inpatient mental health services. You say that you would like reconsideration because the member is acutely ill. The Plan denied your request. The Plan says the requested inpatient mental health services are no longer 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 the continued inpatient mental health services. Our reviewer says that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The member was cooperative and compliant with medication. Our physician reviewer found it does 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. It does not appear that active treatment is taking place beyond the date in question. It does not appear that the services for the dates in question are reasonably expected or medically necessary to improve the member's condition or for the purpose of diagnosis. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of  February 10, 2022 forward and could have been treated in a lesser restrictive 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 continued inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued inpatient mental health services to be provided after February 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the continuation of SNF care. You say that it is imperative that the enrollee regain as much cognitive function and ability to communicate her needs as possible. You say that the enrollee will have more independence if she can work with physical therapy and occupational therapy to increase her strength and move both lower extremities to operate her wheelchair. The Plan denied your request.  The Plan says the enrollee no longer requires killed nursing or therapy services on a daily inpatient basis. The Plan says that the continuation of SNF care is not medically necessary.  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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy, occupational therapy, and speech therapy in the SNF. By the dates in question, the enrollee was at a dependent level with functional mobility. The enrollee required varying assist with activities of daily living. The enrollee tolerated a pureed diet and honey thickened liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve shoulder surgery to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve shoulder surgery. You say that your primary care physician only does referrals for In-network providers. The Plan denied your request. The Plan says an In-network provider was given that can perform the services and is accepting new patients.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.    The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve shoulder surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on October 14, 2020, by an out-of-network provider.  You asked the Plan to pay for psychotherapy services. You say that procedure code 90834 is covered by Medicare. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 psychotherapy services (90834) provided on October 14, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Botox (J0585).  You asked the Plan to pre-approve Botox. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve treatment with Botox (J0585).   Benefits for Botox 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an endodontist.  You asked the Plan to pre-approve these services. You say that your crown fell off and the dentist wants you to see an endodontist. The Plan denied your request. The Plan says the services are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Plan covers services from a general dentist only. Therefore, we decided that the Plan does not have to pre-approve a referral to an endodontist.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa.  You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet criteria for the requested drug.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the member does not meet Medicare criteria for coverage of the requested Euflexxa. Our physician reviewer found the documentation submitted does not include an x-ray which supports degenerative disc 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric services. You say that the requested services are medically necessary. You say that you are experiencing drowsiness with a recent increased dosage of Seroquel which needs to be monitored. You say that you are still experiencing paranoia and having suspicious thoughts. The Plan denied your request. The Plan says the enrollee's condition has improved and he is no longer a threat to himself or others.  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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on February 7, 2022, with Unspecified Mood Disorder. It was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations, and was without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. 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.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
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 IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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 while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the doctors who have been treating you recommended the requested location. You say that a nursing home is not equipped to do rehabilitation. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical conditions are stable with no issues that require a physician's evaluation three or more times per week. The records do not suggest that ongoing intravenous antibiotics will be needed at time of hospital discharge. The enrollee does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Sildenafil Citrate tablets.  You asked the Plan to pre-approve the Sildenafil Citrate tablets. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under Medicare Part B.  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. Therefore, we decided that the Plan does not have to pre-approve the Sildenafil Citrate tablets.   Benefits for the Sildenafil Citrate tablets 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve at home INR testing (CPT code(s): G0248 and G0249)  You asked the Plan to pre-approve the services. You say that you have been getting this service done for about twenty (20) years, and it has been covered. You state the diagnosis listed on the denial for antiphospholipid syndrome has nothing to do with your condition and is incorrect. The Plan denied your request. The Plan says there are participating providers available that can render the service, it was not due to the diagnosis.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.        The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve at home INR testing (CPT code(s): G0248 and G0249)