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

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml subcutaneous injection 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 a step therapy exception cannot be granted.

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 the services. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of preferred drugs (an oral biphosphonate drug (e.g., alendronate, ibandronate, or risedronate), and IV Zoledronic acid (generic Reclast) before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml subcutaneous injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rest home visit provided on August 3, 2021 by an out-of-network (OON) provider.  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 rendered by an out-of-network provider without prior authorization.  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 the rest home visit provided on August 3, 2021 by an out-of-network (OON) provider.
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 enrollee needs admission to an LTACH. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.  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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services rendered on September 24, 2019.  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 claim was not filed timely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.         The record shows that a claim for these services was not filed until August 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the home health services rendered on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on June 15, 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 procedure codes 36215 and 75710 are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 36215 is selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. The definition of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation.  We find that CPT codes 36215 and 75710 are not supported in the medical record. Specifically, there is no documentation of selective catheter placement into the arterial system to support code 36215. There is no documentation of a unilateral extremity angiography with radiological supervision and interpretation to support code 7571-. 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 surgical services rendered on June 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from  May 28, 2021 to May 30, 2021.  You asked the Plan to pay for the SNF care. You say that the SNF care provided was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet Medicare criteria for SNF care provided from May 28, 2021 to May 30, 2021.  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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was with falls and chronic subdural hematomas (SDHs). From a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. He had no signs or symptoms of hyper or hypoglycemia. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a modified independent level with functional mobility including gait to 300 feet with a rolling walker. The enrollee required varying assist with activities of daily living.  There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting 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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 28, 2021 to May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for contact lens fitting provided on July 2, 2021.  You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says that the claim was paid according to the eyewear benefit allowance of $150.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum vision benefit allowance of $150 and you are responsible to pay the difference. Therefore, we decided that the Plan does not have to pay for contact lens fitting provided on July 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on February 1, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance company is billing you for more than your copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan has confirmed with the provider that you only owe $300.  You do not have a responsibility for anything additional on this claim.  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 trip for ambulance services.   You have been asked to pay a $300 copayment per trip for the ambulance services. 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 ambulance services provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has bowel incontinence. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on March 9, 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 procedure codes 14301 and 15738 are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 15738 is muscle, myocutaneous, or fasciocutaneous flap; lower extremity.  We find that CPT codes 14301 and 15738 are not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement of any area of defects 30.1 to 60.0 sq cm to support code 14301. There is no documentation of muscle, myocutaenous, or fasciocutaneous flap from a lower extremity to support code 15738. 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 surgical services rendered on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (00731) provided on September 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the anesthesia services. You say that it is unrealistic to expect a referral to an anesthesia provider from the patient's PCP. Please review the attached anesthesia record and reprocess your claim. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the anesthesia services (00731) provided on September 22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on  July 23, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that you required a second oral evaluation because you used a different dentist. You say that you only wanted a second yearly cleaning. The Plan denied your request. The Plan says a comprehensive oral exam is only covered once every 36 months.  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, you also have a maximum benefit of one comprehensive oral evaluation every 36 months. The Plan paid for the comprehensive oral evaluation provided on February 4, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another 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 above. 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 was medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally given his current level, though he needs PT and OT, he does not require IRF level of therapies. The enrollee may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and lack of medical complexity. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 enrollee currently meets the LTACH admission criteria. You say that the enrollee is stable and suitable for transfer. You say that the enrollee cannot be adequately cared for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the clinical information provided does not show that the guidelines for coverage have been met. The Plan says that the enrollee's needs can safely be met in the current hospital setting.  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 the enrollee was admitted with acute respiratory failure and pulmonary embolism. The enrollee can safely be managed in the current inpatient setting and has all the skilled resources available in the current setting to meet her needs. Clinical stability can safely be achieved in the current setup and can be tapered to a lower level of care, ideally in a skilled nursing facility setting. There are no additional services that an LTACH can provide which cannot be provided in the current setting.  The requested LTACH services would lead to unnecessary futile care and would expose the enrollee to over-treatment. An LTACH setting will not change the prognosis and the outcome of the disease state.  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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from August 12, 2020, to August 13, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you are appealing the copayment on behalf of the enrollee. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for each emergency room visit in the U.S. The enrollee has been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided from August 12, 2020, to August 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to reduce the copayment for an ultrasound of the heart provided on June 29, 2021.  You asked the Plan to reduce the copayment for the ultrasound. You say that you went for a test not knowing you would be charged for outpatient instead of for seeing a specialist. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $160 copayment for radiological diagnostic services, including ultrasounds.   The Plan says you must pay a $360 copayment for the ultrasound. Based on the Plan contract, however, you cannot be asked to pay more than a $160 copayment for the ultrasound. Therefore, we decided that the Plan has to reduce the copayment for an ultrasound of the heart provided on June 29, 2021.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 3 home health visits.  You asked the Plan to pre-approve 3 home health visits. You say that the 3 requested home health visits are medically necessary. The Plan denied your request. The Plan says the 3 requested home health visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 3 home health visits. Our reviewer says that the 3 requested home health visits are not medically necessary. Our physician reviewer found the documentation doesn't support that the member requires additional skilled nursing services to provide treatment that is medically necessary.   The member does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The requested home health services are not 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 3 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home health visits.