Persius/hicric huggingface dataset:
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 enrollee does not need an extended subacute rehab stay at a skilled nursing facility, rather a short intensive IRF stay to get the enrollee home as quickly and as safely as possible. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.  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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dronabinol.  You asked the Plan to pre-approve Dronabinol. The Plan denied your request. The Plan says this is not covered under the enrollee's Part B plan. 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 Dronabinol.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Wakix tablet 17.8mg.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug isn't covered under the medical plan.  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 Wakix tablet 17.8mg.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rasagiline for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have pharmacy (drug) benefits administered by the plan.  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 Rasagiline for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342 x 2) and gingival irrigation (D4921 x 2) provided on July 20, 2021.
You asked the Plan to pay for the dental services. You say that you told your dentist you did not need gingival irrigation. You say that the dentist did it anyway because of your medical issues. You say that you told them that you did not have money to pay for services that are not covered. You also say that you requested a regular cleaning. The Plan denied your request. The Plan says the services denied correctly per your 2021 benefits.
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 gingival irrigation are not among those covered under this benefit. Additionally, services must be performed by a participating general dentist. The record shows that the provider in this case is not a participating general dentist. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342 x 2) and gingival irrigation (D4921 x 2) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intradialytic parenteral nutritional supplements.  You asked the Plan to pre-approve nutritional supplements. You say that this intradialytic parenteral nutrition is needed until the enrollee can maintain nutritional status with oral intake alone. The Plan denied your request. The Plan says the denial of authorization for these nutritional supplements is correct, because the enrollee does not meet the Medicare criteria for coverage.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutritional supplements.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 10, 2021, to May 14, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you don't think it is fair that the enrollee is being asked to pay this copayment since she already paid a copayment to the fire department. The Plan denied your request. The Plan says the $800 bill that the enrollee received was not for ambulance services, it was for inpatient hospital services. The Plan says they attempted to contact you several times to confirm what exactly it was that you were appealing. The Plan says that the $800 copayment for the inpatient hospital services was charged correctly.
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 $200 copayment per day for days 1-5 for inpatient hospital care.
Records show that the enrollee was in the hospital for 4 days. She was charged a $200 copayment per day, for a total of $800. 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 inpatient hospital services provided from May 10, 2021, to May 14, 2021.
Please note that there is a separate appeal related to your question about the ambulance copayment. You will receive a letter under appeal number 1-10471967846 that addresses that service.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits.  You asked the Plan to pre-approve 16 additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 16 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore 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 16 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) coded 70470 and the  CT coded 70492 provided on April 26, 2021.  You asked the Plan to pay for the CT scans. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.   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, we have confirmed that code 70470 for the CT scan is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. We have also confirmed that code 70492 for the CT scans is a column II code to column I code 70498. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) coded 70470 and the CT coded 70492 provided on  April 26, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided on June 4, 2021.  You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the diagnosis codes billed are not valid.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Specifically, the record shows that this claim was billed with valid ICD-10 diagnosis codes. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided on June 4, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the harness upgrade, expandable controller and electronic connection.  You asked the Plan to pre-approve the harness upgrade, expandable controller and electronic conection. You say that you would like reconsideration because the requested accessories are medically necessary. The Plan denied your request. The Plan says you do not meet criteria for the requested accessories.  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 the harness upgrade, expandable controller and electronic conection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested accessories are not medically necessary as you have use of your left hand and can operate and control the power options using the switches that are included in the basic wheelchair. Furthermore, the documentation does not indicate that you have any pressure injuries or require intermittent catheterization of the bladder.  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 harness upgrade, expandable controller and electronic conection have not been met. Therefore, we decided that the Plan does not have to pre-approve the harness upgrade, expandable controller and electronic connection.
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 care can be safely received in another setting, such as the current acute care facility.  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 necessitating 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.  You asked the Plan to pre-approve the RFA procedure. You say that this should be covered. The Plan denied your request. The Plan says this is an experimental procedure.  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 the RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding a genicular nerve block having been provided to the left knee with noted benefit. In addition, there are no imaging studies provided for the knees to evaluate for other potential pathology. Overall, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of these procedures for this enrollee as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested procedure on both knees is not medically reasonable and necessary at this time.  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 RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for medical services provided in Hong Kong from April 14, 2020, through December 31, 2020.  You asked the Plan to pay for the medical services provided in Hong Kong. You say that you became ill, and the services were rendered due to an emergent need. The Plan denied your request. The Plan says that based on the documentation provided, the need for urgent or emergent services cannot be established.  The Plan must follow Medicare rules. Medicare rules say that Medicare only covers services provided outside of the United State and its territories under certain specific circumstances. These services do not fall under any of the circumstances for which Medicare may cover out-of-country services. However, the Plan also has a worldwide coverage benefit that goes beyond Medicare coverage. For that reason, the Plan's rules apply to this case. The Plan covers worldwide services that would be classified as emergency, urgently needed, or post-stabilization care had they been provided in the United States.   We looked at the file, the Plan's rules and the Medicare rules. The file shows that you saw providers in Hong Kong for evaluation and treatment of Polyarteritis nodosa. You could not have reasonably foreseen requiring these services prior to leaving the Plan's service area and the United States. It would not have been medically reasonable to delay the services until you returned to the Plan's service area. Therefore, we decided that the Plan has to pay for medical services provided in Hong Kong from April 14, 2020, through December 31, 2020.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve PADCEV and Keytruda.  You asked the Plan to pre-approve PADCEV and Keytruda. The Plan denied your request. The Plan says these drugs are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 PADCEV and Keytruda. Our reviewer says that PADCEV and Keytruda are not medically reasonable and necessary in this case. Our physician reviewer found that PADCEV and Keytruda are not FDA-approved for the enrollee's diagnosis. These drugs are currently the subject of ongoing phase III trials.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PADCEV and Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve PADCEV and Keytruda.
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 LTACH care is medically necessary. You say that the clinical documentation support that an LTACH is the most appropriate level of care and the most optimal opportunity for a successful outcome. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed 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 necessitating 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on May 26, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that you were billed twice for a laboratory copayment you received at one facility on the same day. You say it was an error by the technician to separate the two laboratory orders. You say only one needle was used in one arm and you think you should not have to pay twice for the bloodwork. The Plan denied your request. The Plan says the cost-share was applied correctly.  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 $15 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.     You have been asked to pay a $30 copayment for laboratory services. Laboratory services falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The claims records for laboratory services on May 26, 2021, indicate two different providers rendered the services. The records also show that one of the lab services was rendered during an office visit. This service was appropriately billed as a separate cost-share, in compliance with your Plan benefits ($15 for Medicare-covered laboratory services ? 2 = $30).   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 laboratory services provided on May 26, 2021.