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

We decided that the Plan does not have to pre-approve Carafate suspension.
You asked the Plan to pre-approve Carafate. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered
under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Carafate suspension.
Benefits for Carafate 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667 x2) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652 x1), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the enrollee has developed bilateral lower extremity edema following chemotherapy treatment for lymphoma. You state a basic device is not appropriate for the enrollee because it cannot provide decongestion of the trunk, so the enrollee is recommended to use at-home pneumatic compression device for life. The Plan denied your request. The Plan says the Medicare rules have not 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 the DME. Our physician reviewer found the criteria for this device includes having truncal edema. This enrollee has no evidence of such as physical therapy (PT) did not treat it and physical exam findings did not show evidence of truncal or pelvic edema. Therefore, the provided records do not support the LCD criteria being 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667 x2) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652 x1), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 3, 2019 to December 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 physician services provided on January 3, 2019 to December 31, 2019 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 IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is not reasonable to expect that you will be able to fully benefit from the intensity of services of an IRF.

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 physician reviewer found that you are at a contact guard assist level for standing, set-up for grooming, minimal assist for toileting, and contact guard assist for walking using a four-wheeled walker. You do not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is still battling symptoms. The Plan denied your request. The Plan says the enrollee has reached a new baseline without evidence of further functional gain.
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. Continued SNF services beyond May 13, 2021, were requested. 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 at the time of admission, you required skilled rehab services to improve function due to weakness and deconditioning. The most recent therapy documentation indicates you made slow and inconsistent progress with therapy services. There were no skilled nursing needs. You are medically stable, do not have any daily complex daily wound care, parental medications, or require care for a new or complicated feeding tube. You no longer require any skilled nursing or rehab services on a daily basis in an inpatient setting at a SNF.
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 continued skilled nursing facility (SNF) services.
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 this is necessary because the enrollee is unable to care for himself. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of 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 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of an ankle fracture after a fall. His medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary services can be provided in a different 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 a 68-year-old man who was admitted to an acute care hospital for COVID pneumonia. The enrollee continues to receive acute care services including high flow oxygen and treatment for acute kidney injury. The acute care services have not been denied and the enrollee does not require services that the facility cannot provide but that could be provided by the LTACH 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this inpatient care is medically necessary. The Plan denied your request. The Plan says the inpatient hospital care following the elective surgery is not medically necessary and reasonable.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 67year old female who has been approved for a Right Reverse Total Shoulder Arthroplasty but the preservice request for an Inpatient admission has been denied. The enrollee is medically stable. The planned procedure listed under CPT codes 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-based composite for teeth #24, 25, 26, 27, 29 and
31 (D2330, D2393, and D2394).
You asked the Plan to pre-approve resin-based composite for teeth #24, 25, 26, 27, 29 and 31. You say that the
services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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. The Plan covers four resinbased
composite fillings per calendar year.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of resin-based composite for teeth #24, 25, 26, 27, 29 and 31 have not been met. Therefore, we
decided that the Plan does not have to pre-approve resin-based composite for teeth #24, 25, 26, 27, 29 and 31
(D2330, D2393, and D2394).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 July 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccine provided on January 13, 2021.
You asked the Plan to pay for the Shingrix vaccine. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says a Shingrix vaccine is not covered under your
Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Shingrix
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine provided on January
13, 2021.
Benefits for the Shingrix vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and implant supported crown (D6066) provided from August 24, 2020, to December 15, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and implant supported crown. You say that you believe these services should be covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation and implant supported crown are not covered by the Plan. The Plan also says that you are responsible for a $14 copayment for the first intraoral periapical x-ray.
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 problem focused limited oral evaluation and implant supported crown are not among those covered under this benefit. The contract says that you are responsible for a $20 copayment for dental x-rays. The allowed amount for the first intraoral periapical x-ray was $14, which is less than the $20 copay, and you are responsible for a $14 copay for this service. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and implant supported crown (D6066) provided from August 24, 2020, to December 15, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ultrasound services provided on December 14, 2020.
You asked the Plan to waive the deductible for the ultrasound services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an ultrasound on the date of service at issue in this appeal. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that must be paid before the Plan will pay their share for Outpatient diagnostic tests. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 deductible that must be paid before the Plan will pay their share for Outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the ultrasound services were received on December 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound services provided on December 14, 2020.
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 LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that the enrollee is a 66-year-old male who was hospitalized and treated for wounds
on both of his feet due to poor blood flow. There is no documentation provided necessitating admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on December 10, 2020.

You asked the Plan to pay for the dental service. You say that you have never had to submit a request for a cleaning. The Plan denied your request. The Plan says unspecified preventive service 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services (99316) provided on October 22, 2020.
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 skilled nursing facility services (99316) provided on October 22, 2020.