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 IRF admission is medically necessary. The Plan denied your request. The Plan says your current functional and medical condition do not support that you require daily skilled services or care in an inpatient setting.
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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies. 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: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 23, 2019 to August 5, 2019 by out of network 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 a non-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 has network providers available who can provide 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 medical services provided on July 23, 2019 to August 5, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an HZV immunization and administration (90750 and
90471) provided on August 1, 2019.
You asked the Plan to pay for the immunization. You say that you would like reconsideration because this is a
necessary preventative injection. The Plan denied your request. The Plan says this immunization is not covered
by your medical Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the immunization.
Therefore, we decided that the Plan does not have to pay for an HZV immunization and administration (90750
and 90471) provided on August 1, 2019.
Benefits for the immunization 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019 by out of network provider.
You asked the Plan to pay for laboratory tests. You say that this testing was provided for a valid diagnosis. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering practitioner is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 medical services provided on July 11, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the intraoral complete set of x-rays
(D0210) provided on August 15, 2019.
You asked the Plan to pay the in network rate for the intraoral complete set of x-rays. You say that you verified
that the dentist was a participating provider. You also say that the office verified coverage with the Plan. The
Plan denied your request. The Plan says the intraoral complete set of x-rays is not listed as a 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, the intraoral complete set of x-rays are
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in
network rate for the intraoral complete set of x-rays (D0210) provided on August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond January 2, 2020.
You asked the Plan to pre-approve the continued inpatient care. You say that the enrollee requires continued care at this level. The Plan denied your request. The Plan says while the initial admission was approved. inpatient care is not necessary as of January 2.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient care. Our reviewer says that the documentation does not support the need for care in the inpatient setting beyond the date in question. Our physician reviewer found This 59-year-old female was admitted to the acute inpatient psychiatric hospitalization on December 26, 2019 with Bipolar Disorder Unspecified, Anxiety Disorder and Benzodiazepine Use Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others, auditory or visual hallucinations and was not showing any aggressive behaviors. She was cooperative and compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care
without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, auditory or visual hallucinations. She is noted to be cooperative and compliant/pleasant with treatment while not showing any aggressive behaviors. 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 continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 30, 2019 by out of network 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 a non-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 has network providers available who can provide 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 medical services provided on August 30, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 21,
2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you did not have an x-ray
performed. You say you had an abdominal ultrasound. The Plan denied your request. The Plan says you have
been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for basic radiological services at a freestanding radiological facility.
You have been asked to pay a $5.83 copayment, which is less than the standard amount, for the ultrasound. The
ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the ultrasound provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of the Epifix bioengineered skin substitute (BSS).
You asked the Plan to pre-approve the Epifix BSS treatment. You say that you feel that this should be approved as you are currently receiving daily wound care and this would reduce the need for visits. The Plan denied your request. The Plan says there is not sufficient documentation submitted of the treatments provided thus far. Without this, criteria are not met.
The Plan follows Medicare rules. Medicare rules say that BSS may be covered for wounds with failed response to a documented 30 day comprehensive wound care program. 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 Epifix BSS treatment. Our reviewer says that the documentation does not support the medical necessity of this BSS at this time. Our physician reviewer found the enrollee in an 82 year old female with an open wound on the right shin/knee area which was caused by a fall 1-2 weeks before a visit on 12/4/2019. As of 1/13/2020 healing has been slow and the prescriber feels Epifix will speed healing. However, the provided medical records do not indicate what standard wound care treatment for at least 30 days with organized comprehensive conservative therapy has been provided for the injury. Thus criteria for the use of the Epifix bioengineered skin substitute are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Epifix BSS treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve use of the Epifix bioengineered skin substitute (BSS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by the physician on October 7, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you feel like this was a
post-operative progress evaluation. You say that you should not be charged for this. The Plan denied your
request. The Plan says the correct copayment has been 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 a $45
copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay a $45 copayment for a specialist office visit. Post-op office visits are still subject
to copayments; therefore, the correct copayment has been applied. A specialist office visit falls within the
physician/practitioner services/in-network/specialist benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for a specialist office visit provided by the physician on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve the Synvisc-One. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says this service is 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 the Synvisc-One. Our reviewer says
that the member does not meet Medicare coverage criteria for the Synvisc-One. Our physician reviewer found
there is no documentation of physical therapy and the imaging submitted indicates mild arthritis. The member
has not had a reasonable trial of conservative therapy.
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 Synvisc-One have not been met. Therefore, we decided that the Plan does
not have to pre-approve Synvisc-One (J7325).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises and therapeutic activities provided on July 18, 2019.
You asked the Plan to pay for the therapeutic exercises and therapeutic activities. You say that the services were not hospice related. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises and therapeutic activities provided on July 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered to you by the physician on August 26, 2019.
You asked the Plan to pay for these services. You say that you went out of state and asked for a referral to be evaluated for parasites. The Plan denied your request. The Plan says the services were not urgent or emergent and were rendered by an out-of-area provider without prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows that you left the Plan's service area after receiving an endoscopy and colonoscopy that came back negative (no parasites). You then sought follow up care without any signs or symptoms of disease outside of the Plan's service area. The services were not for an unforeseen illness or injury. 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 the physician services rendered to you by the physician on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories provided on August 28, 2019 by out of network provider.
You asked the Plan to pay for the wound care set. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not get 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 has network providers available who can provide 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 wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories provided on August 28, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 28, 2019 by an out of network 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 a non-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 has network providers available who can provide 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 medical services provided on June 28, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the comprehensive periodontal evaluation, bone replacement grafts (codes D4263 and D4264), and osseous surgery provided from March 28, 2019 to May 2, 2019.
You asked the Plan to reimburse you for the comprehensive periodontal evaluation, bone replacement grafts (codes D4263 and D4264) and osseous surgery. You say that you would like to be reimbursed for the dental services rendered by this provider. The Plan denied your request. The Plan says these services were performed by an out-of-network provider. The Plan also says that these services are not covered under your plan.
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 contract clearly states that you must pay a 50% coinsurance for out-of-network covered services. Also, bone replacement graft - retained natural tooth - first site in quad, bone replacement graft - retained natural tooth - each additional site in quad, and osseous surgery are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the comprehensive periodontal evaluation, bone replacement grafts (codes D4263 and D4264), and osseous surgery provided from March 28, 2019 to May 2, 2019.
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 services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care 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 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 based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by acute physical medicine and rehabilitation (PMR) or acute rehab nursing 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 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.