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

 We decided that the Plan does not have to pay for an office visit (99213) and the strapping of toes (29550) provided on May 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit and the strapping of toes. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this claim was denied for failure to obtain the required prior authorization, and it was determined the services were not urgent or emergent in nature. The Plan also says that upon review, an authorization was not obtained prior to the services being rendered and the provider is not participating with the member's Plan.  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 an office visit (99213) and the strapping of toes (29550) provided on May 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a specialist office visit (99204, 99213) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a specialist office visit. You say that you want to be redirected to this provider because he said he could perform the surgery to help save your ankle/foot. You also say you do not want to see the provider the authorization was changed to because you have legal charges against him and do not want to see him. The Plan denied your request. The Plan says the notes received from your doctor do not support the need for this service, and the services were determined to be available within the Plan network. The Plan also says that out-of-network services, unless emergent in nature, or not available within the Plan network are not considered medically necessary.  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 a specialist office visit (99204, 99213) to be provided 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 a specialist office visit provided on June 8, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you saw a different provider. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for physician specialist services.   You have been asked to pay a $40 copayment for the specialist office visit. The specialist office 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 office visit provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214), a therapeutic, prophylactic, or diagnostic injection (96372), and a ketorolac tromethamine injection (J1885), provided on August 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit, a therapeutic, prophylactic, or diagnostic injection, and a ketorolac tromethamine injection. You say that due to short time of period, you were unable to get the authorization before the service was done. You also said this was necessity of service and have submitted supporting documentation. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 an office visit (99214), a therapeutic, prophylactic, or diagnostic injection (96372), and a ketorolac tromethamine injection (J1885), provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee had coronavirus and has wounds that will require special training. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee needs to stay in an acute care hospital until he is better.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition and medications and IV antibiotics. The enrollee continued to require blood transfusion and was being evaluated for an IVC filter with his anti-coagulation being held. The enrollee had multiple wounds requiring care. The enrollee received physical therapy and occupational therapy. The enrollee was at a total assist level with functional mobility and required varying assist with activities of daily living. There are identifiable skilled nursing service needs, but they are not required on a daily basis. There are not any 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 enrollee is stable and ready for transfer to LTACH. You also say that the enrollee has been inpatient for 25 days. The Plan denied your request. The Plan says the LTACH admission is not medically necessary.  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 provided documentation indicates that enrollee is receiving appropriate care at the present acute care hospital. The reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The reviewer found that 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. Therefore, the reviewer found that 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. Specifically, the file does not show that the enrollee requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 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 this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another 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 there is no documentation provided indicating medical necessity for admission to a 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 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states they could review alternate settings if requested such as skilled nursing facility, outpatient setting or home health 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 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 was admitted for back pain, weakness, shortness of breath, and myopathy after recent Coronavirus infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has 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 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on September 15, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on September 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen provided on September 24, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you were not charged a copayment at the time of service. 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 $150 copayment for each radiological diagnostic service, including ultrasounds.   You have been asked to pay $119.59, which is less than the $150 copayment for the ultrasound. The ultrasound 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 of the abdomen provided on September 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 this is medically necessary. The Plan denied your request. The Plan says this is 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 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 is medically stable.  With comorbid conditions being stable, the enrollee does not need physician supervision three times per week (at a minimum), for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehabilitation nursing needs noted in the record. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity, and rehab nursing needs. While the enrollee may benefit from PT, and OT, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in an SNF.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for skin substitute applications performed from February 11, 2021, to March 4, 2021.  You asked the Plan to waive the copayments for the skin substitute applications. You say that the amount charged is outrageous for the services provided. 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 $225 copayment for surgery or other services provided to you at an ambulatory surgical center.   The file shows that you had three total procedures from February 11, 2021, to March 4, 2021. Therefore, you have been asked to pay a $225 copayment for each of the skin substitute applications. The total for the three procedures is $675 ($225 copayment x 3 procedures = $675). The skin substitute applications fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayments for skin substitute applications performed from February 11, 2021, to March 4, 2021.
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 is in a very infectious environment and would benefit from the more controlled environment of the LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 is receiving acute hospital care services which have not been denied. The enrollee does not require services at the LTACH that are not available at the health care setting being offered by the 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Purewick Catheter (CPT code A9270), for the enrollee.  You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not covered by Medicare or the health plan.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    PureWick is for member convenience only. Therefore, an external urinary collection device is not medically necessary. In addition, per PureWick website (https://www.purewickathome.com/faq.html) "The PureWickTM Urine Collection System and its accessories are not currently eligible for Medicare reimbursement." Therefore, we decided that the Plan does not have to pre-approve Purewick Catheter (CPT code A9270), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  You asked the Plan to pre-approve Prolia. You say that the enrollee has a history of poor swallowing. You say that the enrollee also has absorption issues. You also say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, zoledronic acid.  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 Prolia. Our reviewer says that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, zoledronic acid. The reviewer also found that the provided documentation does not indicate that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy requirements for Prolia have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).