Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for enrollee.You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive rehab with daily physician visits.The Plan denied your request. The Plan says the enrollee's condition is not medically complex, and does not require an interdisciplinary approach to rehab 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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is functioning at maximal to moderate assist for activities of daily living. She was at supervision for ambulation and transfers. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that her medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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 for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on October 22, 2019.You asked the Plan to waive the copayment for the podiatry visit. You say that you were told there would be no copayment for a diabetes visit or nail clippings. 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 $15 copayment for each in-network Medicare-covered visit (medically necessary foot care). Youhave been asked to pay a $15 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The medical record shows you were seen for diabetic foot care and treatment of pain in left and right toes and toenailfungus.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 forthe podiatry visit provided on October 22, 2019.
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-approvethe LTACH services. You say that the enrollee meets LTACH admission criteria.The Plan denied your request. The Plan says the enrollee's needs could be met in a different setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for hypoxic respiratory failure. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate fora crown (D2740) for tooth # 5, core build up (D2950) for tooth # 5, the topical application of fluoride (D1206), 2D oral or facial photographic images (D0350 x 4), the periodontal scaling and root planing (D4342 x 3), the gingival irrigation (D4921 x 4), the unlisted periodontal service (D4999 x 4), the endodontic therapy (D3320), and the pulp vitality test (D0460) provided from October 18, 2019 to October 24, 2019.You asked the Plan to pay the in network rate fora crown and core build up for tooth #5, the topical application of fluoride, 2D oral or facial photographic images, the periodontal scaling and root planing, the gingival irrigation, the unlisted periodontal service, the endodontic therapy, and the pulp vitality test. You say that you wereassured by the provider's office that they were in network with the Plan. You say thatThe Plan denied your request. The Plan says the frequency limit of 1 crown per calendar year has been exceeded. The Plan also says that the topical application of fluoride, 2D oral or facial photographic images, periodontal 
scaling and root planing, gingival irrigation, unlisted periodontal services, endodontic therapy, and pulp vitality test are not listed as covered service.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 and crowns are a covered service, the frequency limit has been exceeded. Additionally, the remaining services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate fora crown (D2740) for tooth # 5, core build up (D2950) for tooth # 5, the topical application of fluoride (D1206), 2D oral or facial photographic images (D0350 x 4), the periodontal scaling and root planing (D4342 x 3), the gingival irrigation (D4921 x 4), the unlisted periodontal service (D4999 x 4), theendodontic therapy (D3320), and the pulp vitality test (D0460) provided from October 18, 2019 to October 24, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and endodontic therapy (D3310) for tooth # 6.
You asked the Plan to pre-approve the core build up and endodontic therapy for tooth # 6. You say that the enrollee has a grossly decayed tooth # 6. You say that there is a large filling with recurrent decay, discomfort and sensitivity with periapical radiolucency. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that endodontic therapy is listed as NC or not covered.
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 requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and endodontic therapy (D3310) for tooth # 6.
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 meets the LTACH admission criteria under CMS guidelines. You say that all of the enrollee's attending physicians agree that the enrollee is stable and appropriate for transfer to an LTACH.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a small bowel obstruction and renal failure. The enrollee has undergone corrective surgery and been started on hemodialysis. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) and supplies.You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says that this is not covered for your condition.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical services provided on October 15, 2019.You asked the Plan to waive the coinsurance for surgical services. You say that you are requesting reimbursement for these services because you have paid the full amount you were asked.The Plan denied your request. The Plan says the coinsurance amount you are being charged is 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 20% coinsurance for out-of-network outpatient surgery received in Puerto Rico using the Plan's Point-of-Service (POS) benefit. The Medicare allowed amounts for these services total $1,298.03. Therefore, your coinsurance obligation is $259.60, and the Plan has issued you reimbursement in the amount of $1,038.44. The Plan is not required to consider reimbursement of any amounts paid beyond the Medicare allowable amounts for services.You have been asked to pay 20% coinsurance for surgical services. Surgical services 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 coinsurance for surgical services provided on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that you are unable to go home, as you need assistance to function.The Plan denied your request. The Plan says alternate settings can be 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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable with no evidence of need for supervision by PMR Physician or need for acute rehab nursing care. You may benefit from further PT and OT,but you do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. You should continue SNF rehab.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for inpatient surgery services provided from November 21, 2018 to November 24, 2018.
You asked the Plan to hold you harmless for inpatient surgery services. You say that this should be covered. The Plan denied your request. The Plan says that these services were not authorized.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. You received inpatient surgery services.The file does not show that the plan provided notice that inpatient surgery services would not be covered. Under Medicare rules, this means inpatient surgery services is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for inpatient surgery services provided from November 21, 2018 to November 24, 2018.
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 the SNF services. You say that you would benefit from short-term rehabilitation.The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF coverage because she does not require skilled care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee was treated for a urinary tract infection. The enrollee received physical therapy and occupational therapy in the skilled nursing facility. The enrollee was at contact guard assist level with bed mobility and gait to 40 feet. The enrollee required minimal to maximal assist with transfers and required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness of intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the 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 pre-approve Implant/abutment supported removable denture for edentulous arch (D6111).You asked the Plan to pre-approve the dental services. You say that you are recommending that the enrollee has a mandibular locator style implant to stabilize a future lower complete denture.The Plan denied your request. The Plan says this service is not covered under the benefits package.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve Implant/abutment supported removable denture for edentulous arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefrenulectomy (D7960x2).You asked the Plan to pre-approvethe 2 frenulectomy. You say that you are requesting reconsideration because you do not have the money to pay for this procedure.The Plan denied your request. The Plan says the requested service is not a covered benefit.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvefrenulectomy (D7960x2).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve methylprednisolone sodium succinate (J2930). You asked the Plan to pre-approve methylprednisolone sodium succinate. You say that the requested medication is necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.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 methylprednisolone sodium succinate. Our reviewer says that the medication is medically necessary. Our physician reviewer found the report in the provided records indicated symptoms consistent with an acute flare of her multiple sclerosis on January 2, 2020. Methylprednisolone sodium succinate at a dose of 1000 mg intravenous each day for three days is medically reasonable and necessary for these symptoms.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of methylprednisolone sodium succinate have been met.Therefore, we decided that the Plan has to pre-approve methylprednisolone sodium succinate (J2930).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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve insertion of pacing electrode, cardiac venous system for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is supported for non-right bundle branch block with QRS greater than 120 msec.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found although the enrollee does not have a baseline LBBB and QRS >0.12 in the setting of CHF currently, the plan is to control his atrial fibrillation with an AV nodal ablation. He has symptomatic heart failure on guideline directed medical therapy and his EF is 29%. Once the AV node is ablated he will be pacemaker dependent and if he only has a single RV pacing lead, his QRS will be >0.12 in a left bundle branch block pattern consistent with complete RV pacing. He would then qualify for a Bi-ventricular ICD based on these ECG and clinical criteria. Since this will be the ultimate ECG outcome of the planned AV ablation, he will require a biventricular ICD to be implanted first as he will be completely pacemaker dependent after the AV nodal ablation. Therefore placement of the Biventricular ICD is medical necessary and appropriate prior to the AV nodal ablation as he will meet the biventricular ICD implantation criteria at that time following the AV node ablation. 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 been met. Therefore, we decided that the Plan has to pre-approve insertion of pacing electrode, cardiac venous system for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says there are no symptoms indicative of lung cancer.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the CMS guidelines for low dose lung CT specify that a patient must be 55-77 years old, have at least a 30 pack year smoking history, be asymptomatic and either currently smoking or having quit within the past 15 years. Nowhere does CMS mention family history -the enrollee is asymptomatic with a family history of lung cancer. In addition, while the enrollee is in the covered age group, the pack year history is not stated and he quit in 1993, greater than the 15 year allowable per CMS guidelines. 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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.