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

 We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on October 27, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 pay for these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether the requested genetic testing was medically reasonable and necessary. The test is described by the manufacturer, Redwood Lab Services, as a genetic-based hereditary cardiomyopathy risk factor screening test in which 62 genes are assessed using genomic DNA extracted from buccal swabs. The test has not been approved by the FDA.  It is not a diagnostic test. It assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. This patient has known coronary artery disease, and the test results would play no role in her medical management. In summary, the requested testing is not considered reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee on October 27, 2020.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Botox.  You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says that this drug is not covered by Medicare Part B since it is not a buy/bill situation.  While the Plan states that this drug is not covered by Medicare Part B since it is being provided by the hospital, this is untrue per Medicare rules. Non-self-administered drugs provided by an outpatient facility are covered by Medicare Part B.  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 Botox. Our reviewer says that the documentation supports that the requested Botox is medically reasonable and necessary. Our physician reviewer found the enrollee has a past medical history of pelvic prolapse and overactive bladder with urinary incontinence. The records indicate that the enrollee has had a positive response from prior Botox injections. Based on the medical records provided and the Medicare-approved major drug compendia there is documentation that the Botox is medically reasonable and necessary for the patient. Botox is Food and Drug Administration approved for overactive bladder; this is a continuation of therapy that has been documented successful and well tolerated by 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 Botox have been met. Therefore, we decided that the Plan has to pre-approve Botox.   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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found Based on the documentation provided, the enrollee does not have documented skilled therapy needs.  The enrollee is ambulating household distances. The enrollee will remain limited with ADLs due to her left upper extremity weight bearing restriction. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Ondansetron oral dissolving tablet (ODT).  You asked the Plan to pre-approve Ondansetron ODT. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not, as prescribed in this case, among the types which are covered by Medicare Part B. Specifically, the record indicates that the requested drug will not be initiated within 2 hours of the administration of the chemotherapeutic agent and be continued for a period not to exceed 48 hours from that time; nor will the requested drug be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve treatment with Ondansetron oral dissolving tablet (ODT).   Benefits for Ondansetron ODT may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 23, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  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 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 out of network physician services provided to the enrollee on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from April 28, 2021, to April 30, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you do not understand these bills. The Plan denied your request. The Plan says this claim was processed correctly; you are responsible for $328 per day of inpatient care through the first six days of an inpatient admission. There is a $0 copayment for additional days in the same stay.  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 $328 copayment for each of the first six days of an inpatient stay.    You have been asked to pay a $656 copayment for two days of inpatient hospital care ($328 x 2 days = $656). 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 the inpatient hospital admission and services provided from April 28, 2021, to April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for seven office visits provided from August 4, 2020, to November 10, 2020.  You asked the Plan to waive the copayment for office visits. You say that you have been taking oxycodone since 2001 for a chronic pain condition. You started treatment with the provider to determine if you still need to take the prescription. You say you have tried every remedy to get off the medication with no success. You state the provider only saw you for 10 minutes each time, rather than the 30 minutes billed. You also say that no drug test was administered. The Plan denied your request. The Plan says the medical notes submitted by the provider indicate an office visit with a urine drug screening was performed. The Plan says you are responsible for the charges.  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 $5 copayment for each Medicare-covered PCP office visit. Your contract also says that you must pay a $10 copayment for Medicare-covered lab tests in a doctor's office setting, in addition to the applicable office visit copayment.   You have been asked to pay $95 in copayments for seven office visits and drug tests. Office visits fall within the Physician/Practitioner Services benefit category whereas drug testing falls within the Outpatient Diagnostic Tests benefit category. The Plan paid for the drug testing in full for the office visit on August 4, 2020, leaving you responsible for a lesser amount on that date of service. See below for a breakdown of your copayments.   August 4, 2020: $5 (office visit only) August 11, 2020: $15 August 18, 2020: $15 September 1, 2020: $15 September 15, 2020: $15 October 13, 2020: $15 November 10, 2020: $15 Total: $15 ? 6 visits = $95 + $5 (August 4, 2020) = $95  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 seven office visits provided from August 4, 2020, to November 10, 2020.   Your complaint about reportedly being seen for only 10 minutes while being billed for 30 minutes is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve personal care services, per 15 minutes, (T1019).  You asked the Plan to pre-approve personal care services. You say that you have an authorization for personal care services. You say that there is no agency available to fulfill this benefit. You also say that you did not receive an assessment. The Plan denied your request. The Plan says the requested care is custodial in nature. The Plan also says that custodial care is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services, per 15 minutes, (T1019).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Euflexxa.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.  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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records contain radiographic evidence of moderate to severe bilateral knee osteoarthritis with ostephytes and joint space narrowing. She has ongoing pain and joint swelling despite treatment with ibuprofen, methadone, gabapentin, Tylenol, and multiple joint aspirations and corticosteroid injections. Euflexxa is approved by the Food and Drug Administration (FDA) for pain related to osteoarthritis of the knee that has not responded to conservative non-pharmacological therapy or simple analgesics. The Euflexxa is safe and effective and reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Euflexxa.   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: 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. The Plan denied your request. The Plan says your needs are considered custodial.  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 physician reviewer found that from a nursing perspective, you had stable vital signs, tolerated a regular diet, and was treated for left hip pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you are dependent with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the prophylaxis, periodic oral evaluation and intraoral x-ray provided on April 15, 2021.

You asked the Plan to pay more toward the prophylaxis, periodic oral evaluation and intraoral x-ray. You say that this is regular dental maintenance and should be paid. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network 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 Plan is only obligated to pay 50% of the allowed amount for a periodic oral evaluation and prophylaxis from an out-of-network provider. You are responsible for any amount greater than the payment made by the Plan to the out-of-network provider. You are also responsible for the full cost of the intraoral x-ray as it is a non-covered benefit. Therefore, we decided that the Plan does not have to pay more toward the prophylaxis, periodic oral evaluation and intraoral x-ray provided on April 15, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.  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. 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 care. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found based on the medical records provided, the enrollee has documented skilled therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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 a portable home ventilator.  You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says ventilators for the requested use are not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a ventilator. Our physician reviewer found that the enrollee has a diagnosis of COPD, although spirometry is most consistent with restrictive lung disease. The enrollee also has obstructive sleep apnea (OSA), heart failure with preserved ejection with exacerbations of volume overload, and possible obesity hypoventilation syndrome. Recurrent episodes of acute on chronic hypercarbic respiratory failure are likely related to all of these diagnoses. The enrollee reportedly did not tolerate continuous positive airway pressure (CPAP) for OSA; it was not clear from the records whether the OSA is currently being treated.  This enrollee may benefit from BiPAP support at night using a device that can provide the AVAPS mode of support. A home ventilator is not necessary to provide AVAPS, and Medicare does not cover a home ventilator when used as BiPAP.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility.  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.