Persius/hicric huggingface dataset:
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 27, 2021 with acute on chronic respiratory failure requiring tracheostomy and ventilator support and acute on chronic kidney failure requiring hemodialysis. The enrollee is receiving appropriate care at the present acute care facility. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 diabetic testing strips to test blood sugar 4 times per day.

You asked the Plan to pre-approve testing strips. You say that you think preventing your condition from getting worse is beneficial. The Plan denied your request. The Plan says the denial of authorization for this quantity of testing strips is correct, because you can utilize up to 100 test strips every 3 months.

The Plan follows Medicare rules. Medicare rules state that high utilization of diabetic testing strips may be covered for enrollees who meet certain criteria.

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 testing strips. Our reviewer says that you do not meet the Medicare criteria for the requested quantity of testing strips. Our physician reviewer found you test your blood sugar 4 times per day. The submitted laboratory reports indicate that you have a sugar of 115 milligrams per decileter and a hemoglobin A1c of 6.1%. The information provided is insufficient to determine whether the coverage criteria have been met, so the requested quantity of testing strips cannot be recommended based upon the information provided.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for high utilization coverage of testing strips have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic testing strips to test blood sugar 4 times per day.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6750 x 2) and the pontic (D6242) provided on October 27, 2020.
You asked the Plan to pay for the dental services. You say that your previous bridge fell out about 5 months ago. You say that the dentist recommended a new procedure to put a tooth back in more permanently. You say that your estimate shows the work is for crown work and should be paid at 30%. You also say that the service is to replace a tooth that failed 20 years ago and not for cosmetic reasons. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic is not listed as a covered service either. The Plan also says there is no record that you contacted them prior to receiving the services to verify benefits and provider eligibility.
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 retainer crowns (D6750 x 2) and the pontic (D6242) provided on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a face bone graft (21210), excision of facial bones (21026), impression and custom preparation (21085), interim prosthesis (21079), jaw reconstruction (21249), and panoramic x-ray (70355).
You asked the Plan to pre-approve the face bone graft, excision of facial bones, impression and custom preparation, interim prosthesis, jaw reconstruction, and panoramic x-ray. You say that it is medically necessary that the enrollee receive these procedures. The Plan denied your request. The Plan says medical necessity has not been established.
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 pre-approve the face bone graft, excision of facial bones, impression and custom preparation, interim prosthesis, jaw reconstruction, and panoramic x-ray. Our reviewer says that the services requested do not meet the criteria for coverage due to medical necessity. Our physician reviewer found the review of the documentation provided was not sufficient to determine if the condition being treated was the result of a medical condition. Our reviewer also found that there was no medical record and the radiographs provided were not of diagnostic quality. 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 face bone graft, excision of facial bones, impression and custom preparation, interim prosthesis, jaw reconstruction, and panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pre-approve a face bone graft (21210), excision of facial bones (21026),
impression and custom preparation (21085), interim prosthesis (21079), jaw reconstruction (21249), and panoramic x-ray (70355).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat medial branch block (MBB).
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a repeat MBB is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic axial low back pain. He underwent diagnostic MBBs and achieved 40 to 60 percent pain relief. The Medicare criteria require at least 80 percent pain relief to be considered a positive finding. The criteria are not met; therefore, the repeat MBB is not 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 pre-approve a repeat medial branch block (MBB).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic vision exam provided on October 5, 2020.
You asked the Plan to waive the copayment for the diagnostic vision exam. You say that you should not have to pay because your appointments were scheduled wrong. The Plan denied your request. The Plan says you were charged the copayment correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a copayment. We looked at the file and the Plan's rules. The ophthalmologist submitted the claim as a medical examination and evaluation, with initiation or continuation of diagnostic and treatment program. Based on this information, we decided that the Plan's rules for coverage of the diagnostic vision exam have been met. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic vision exam provided on October 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray.

You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because you thought telehealth visits did not have a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for basic radiological services provided at an outpatient hospital facility.

You have been asked to pay a $100 copayment for an X-ray. An X-ray 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 an X-ray.
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. You say that the member needs SNF admission to help to him return to normal. The Plan denied your request. The Plan says that the enrollee is receiving the appropriate care in the Inpatient Rehabilitation Facility.
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 the enrollee's 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that the restaurant called for this service and you were only treated in place by the medics without transport. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular pathology procedure provided on
October 28, 2020.
You asked the Plan to pay for the molecular pathology procedure. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the molecular pathology procedure. 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 a molecular pathology procedure provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for eyewear (V2025) purchased on October 29, 2020.
You asked the Plan to pay the full cost for eyewear. You say that you needed these glasses. The Plan denied your request. The Plan says these processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Although the Plan covers frames and lenses, you are responsible for any amount over a $100 retail price. We looked at the file and the Plan's rules. The record shows that the eyewear at issue had a retail price of over $100. You are responsible for the remaining amount. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to pay the full cost for eyewear (V2025) purchased on October 29, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met at a skilled nursing facility.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia and respiratory failure. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tagrisso.
You asked the Plan to pre-approve Tagrisso.. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Tagrisso.
Benefits for Tagrisso. 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 pre-approve proton beam therapy with guidance.
You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is being considered to reduce cardiac and lung doses based on competing photon plans. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no evidence that the enrollee's type of cancer responds better to proton beam therapy than intensity-modulated radiation therapy.
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 pre-approve proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for this case, while the proton therapy plan is provided, the requesting radiation oncologist did not provide a comparative plan. It is possible that this case represents an exceptional case for which proton therapy is necessary, but nothing in the medical records suggests this. What would justify the need for proton therapy is the following:
-A letter (or any records) from the referring physician documenting that IMRT planning was
unacceptable in this patient. Ideally, a draft of the plan that was unacceptable should be provided.
-A comparison of a radiation plan that shows that proton therapy results in meaningful reduction in the
lung V20, and a well-designed VMAT/IMRT results in an unacceptable plan (based upon consensus
dosimetric constraints- QUANTEC, NCCN, cooperative group studies).
-A comparison of a radiation plan that shows that proton therapy results in meaningful reduction in the
cardiac exposure (using accepted constraints), and a well-designed VMAT/IMRT results in an
unacceptable plan (based upon consensus dosimetric constraints- QUANTEC, NCCN, cooperative
group studies).
Without this information, the need for proton therapy is not plausible and well-justified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy with guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet rich plasma injection.
You asked the Plan to pre-approve platelet rich plasma injection. You say that you need this because you have pain and tightness in your muscles. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is experimental/investigational.
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 pre-approve platelet rich plasma injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of platelet rich plasma injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested item is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided October 2, 2020.
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that these items were medically necessary. The Plan denied your request. The Plan says that there is no evidence the provider examined the enrollee.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for a knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided October 2, 2020.