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 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services without transport provided on December
15, 2020.

You asked the Plan to pay for ambulance services without transport. You say that the Plan should pay this
charge. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport. Medicare has also instituted a conditional waiver for this rule for the duration of the
Coronavirus pandemic.

The ambulance company did not provide transport services on December 15, 2020. There is no indication that
the absence of transport services was due to a regional emergency situation related to the Coronavirus
pandemic. The ambulance benefit is a transportation benefit. When there is no transport and the Coronavirus
waiver does not apply, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that
the Plan does not have to pay for ambulance services without transport provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
March 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 services provided by an out-of-network provider on March 2,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology testing provided on May 12, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the cytopathology testing. You say that the service you billed for was referred to
you by an authorized provider. The Plan denied your request. The Plan says no prior authorization was
obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to
pay for the cytopathology testing provided on May 12, 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the home health services provided January 5, 2021, to February 2, 2021.
You asked the Plan to pay for the home health services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says that payment is not allowed when you bill more than 30 days on a home health partial episode payment claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has failed to substantiate their denial. Specifically, the record does not demonstrate that the provider is billing more than 30 days on a home health partial episode claim. This claim from January 5, 2021, to February 2, 2021 does not illustrate a claim period of more than 30 days. Therefore, we decided that the Plan has to pay for the home health services provided January 5, 2021, to February 2, 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 additional home health services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says there are
no skilled needs identified.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our physician
reviewer found that there is no documentation that skilled nursing services are required to provide services in
order to improve your condition, or to establish a maintenance program to maintain your condition or prevent
deterioration. The available records do not document an acutely unstable condition which requires skilled
nursing services beyond what was already approved by the Plan. The records do not document why the
approved visits are inadequate to address your condition and health needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia.
You asked the Plan to pre-approve general anesthesia. You say that local anesthesia is not adequate for these services. The Plan denied your request. The Plan says there are no underlying medical condition that would require general anesthesia.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve general anesthesia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 27, 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 laboratory services provided on May 27, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for online yoga classes.

You asked the Plan to pay for online yoga classes. You say that you had anxiety about going out and were afraid to get sick. You say that this was the only way to participate in an exercise program and helped your mental state. The Plan denied your request. The Plan says online fitness classes are not a covered benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover online fitness classes.

The Plan's rules for coverage of gym benefits have not been met because online fitness classes are not covered by the wellness allowance benefit. Therefore, we decided that the Plan does not have to pay for online yoga classes.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peroral endoscopic myotomy.
You asked the Plan to pre-approve a peroral endoscopic myotomy. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested procedure have not been met because the enrollee does not have a diagnosis of achalasia.
The Plan must follow Medicare rules. Medicare rules say that a POEM procedure may be considered medically necessary for treatment of symptomatic, monometrically proven primary idiopathic achalasia. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a peroral endoscopic myotomy have not been met. Specifically, the provided medical records do not state that the enrollee has a diagnosis of achalasia. Therefore, we decided that the Plan does not have to pre-approve a peroral endoscopic myotomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.

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 you are receiving appropriate care at the present acute care hospital. There are no
services available at the LTACH that you require that are not available at the health care setting being offered
by the health 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI), spinal canal and contents (72148) provided October 13, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you have paid different copays multiple times for different tests and you are becoming concerned that there is a real issue since it has not healed. The Plan denied your request. The Plan says the claim was reprocessed and the correct copayment has been applied per the Evidence of Coverage.
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 $50 copay for covered diagnostic radiology services in a provider's office or freestanding radiology center.
You have been asked to pay $50 copay for the diagnostic services. The diagnostic service 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 magnetic resonance imaging (MRI), spinal canal and contents (72148) provided October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz for the enrollee.

You asked the Plan to pre-approve Supartz. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet all the requirements for additional treatment.

The Plan follows Medicare rules. Medicare rules say that Supartz can be covered if LCA criteria have been met. 

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 Supartz. Our reviewer says that Supartz is not medically reasonable and necessary for the enrollee. The record indicates that the enrollee has osteoarthritis of the knees and last had a hyaluronic acid injection in April 2021 that did not provide significant improvement in pain and functional capacity. The elements of the coverage criteria are not satisfied. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Supartz. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).

You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). The Plan denied your request. The Plan says this service is only allowed one time in 5 calendar years.

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 Plan paid for the complete upper and lower denture provided on May 31, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 200 units of Botox.
You asked the Plan to pre-approve 200 units of Botox. You say that you were using 100 units of Botox and have failed other routine medications. You say that you are requesting approval of 200 units of Botox. The Plan denied your request. The Plan says the use of Botox is only supported when the dose does not exceed 100 units.
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 200 units of Botox. Our reviewer says that there is no documentation that supports that 200 units of Botox meet Medicare criteria of medically reasonable and necessary for an overactive 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 200 units of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve 200 units of Botox.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ambulance services (A0427, A0425) provided on September 22, 2020.

You asked the Plan to waive the coinsurance for ambulance services. You say that you disagree with the amount charged. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 40% coinsurance for each one-way Medicare-covered trip with an out-of-network provider. 

You have been asked to pay $218.21, or 40% of the Medicare-allowed charge of $545.54, for ambulance services provided by an out-of-network provider. 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 ambulance services (A0427, A0425) provided on September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy services provided from
January 7, 2021, to February 18, 2021.
You asked the Plan to waive the coinsurance for chemotherapy services. You say that you were not charged
anything for chemotherapy in 2020. The Plan denied your request. The Plan says the coinsurance applied was
correct.
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 chemotherapy/radiation drugs.
You have been asked to pay 20% coinsurance for chemotherapy services. Chemotherapy services falls 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 chemotherapy services provided from January 7, 2021, to February 18, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the services. You say that the authorization should be reconsidered, and extended care should be approved. The Plan denied your request. The Plan says skilled services are no longer required.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs appear to be custodial and, as a practical matter, can be provided at a lower 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.