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

We decided that the Plan does not have to waive the copayment for an Emergency Room visit provided January 12, 2020.
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the Emergency Room visit. The Emergency Room visit falls within the Emergency Care 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 Emergency Room visit provided January 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 24, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac (SI) joint.
You asked the Plan to pre-approve SI joint radiofrequency ablation. You say that this procedure was done in the past and covered by another health plan. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because radiofrequency ablation of the SI joint is experimental/investigational and is not proven to be helpful for your conditions.
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 SI joint radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found peer-reviewed medical literature states that radiofrequency ablation for denervation whether performed using traditional, cooled, or pulsed radiofrequency is considered experimental and, therefore, not medically reasonable or 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 SI joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve metal cap on 3/4 tooth for bridge teeth 29, 31 (D6781)
and false tooth for bridge tooth 30 (D6211).
You asked the Plan to pre-approve the dental services. You say that the services are needed because you have
severe toothaches and are unable to eat because of it. The Plan denied your request. The Plan says the medically
necessary criteria is not met for the requested services.
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 the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found tooth #31 had succumbed to decay and was treatment planned for endodontic
treatment. The existing bridge would not be functional after root canal treatment and the decay present on the
distal would need to be restored, though not necessarily with a replacement bridge. Plan provisions only allow
for anterior bridges - "Bridges (excluding third molars) are covered to replace one (1) upper front tooth or two
(2) adjacent lower front teeth and there cannot be any missing back teeth." In this instance the request is to
replace a posterior bridge, and therefore under the Plan provisions would not be medical necessity to replace
the bridge.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve metal cap on 3/4 tooth for bridge teeth 29, 31 (D6781) and false tooth for bridge tooth
30 (D6211).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Short Tandem Repeat (STR) markers testing rendered on January 8, 2019.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 not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of prostatic adenocarcinoma. The case file does not contain documentation demonstrating that the Short Tandem Repeat (STR) markers testing would impact the management and outcome of the enrollee in this case. The testing was therefore 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 pay for the Short Tandem Repeat (STR) markers testing rendered on January 8, 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) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says there must be a reasonable expectation that the criteria is met upon admission.
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 records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication
management, wound and O2 ongoing care, and daily therapy can be provided at a SNF. It is not clear that the
enrollee would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer
duration of therapy may be more appropriate.
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) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services (99285, 36556) provided
November 1, 2019.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99285, 36556 is not supported in the medical record. Specifically, the record shows this
claim is a duplicate of another claim for the same date of service. Based on this information, we decided that
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the
Plan does not have to pay for Emergency Room Services (99285, 36556) provided November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
February 22, 2020.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says that there is a $250 copayment for ambulance services.
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 $250
copayment for each separate Medicare-covered ambulance service.
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls
within the Medicare-covered ambulance service 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 ambulance transport provided on February 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 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 this is not medically necessary.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services after 07/16/2020. The specialized skill, knowledge and judgement of a skilled professional nurse or qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require services on an inpatient basis. Further services in the long-term care facility on a part time basis appears appropriate in this case.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 not been met.Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a small portable purse oxygen concentrator.You asked the Plan to pre-approve a small portable purse oxygen concentrator. You say that your current portable concentrator is limiting your mobility and access to the community for shopping and personal events.The Plan denied your request. The Plan says rental of a new concentrator would duplicate the existing concentrator.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file showsthat you have aportable oxygen concentrator. Your portable oxygen concentrator serves the same purpose as a small portable purse oxygen concentrator.There is no physician order or new Certificate of Medical Necessity supporting medical necessity of the requested item. Therefore, we decided that the Plan does not have to pre-approve a small portable purse oxygen concentrator.
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 records provided support the need for IRF care. You say that the enrollee is medically stable for discharge to acute rehab. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelow-dose radiation therapy for multiple skin cancer sites.You asked the Plan to pre-approve the requested radiation therapy. You say that this is a medically necessary treatment.The Plan denied your request. The Plan says there is no reason provided that this would be necessary as surgery is not contraindicated.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 requested radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiation is a standard approach to the treatment of skin cancer, and is often preferred over surgery when resection is likely to result in unacceptable morbidity or cosmesis. Many factors determine which of many treatments are best suited for an individual patient-including histology (squamous cell or basal cell carcinoma), size (T stage), depth, location, comorbidities. For this case, there are no records which support the rationale for radiation in this patient. Moreover, it appears that "superficial radiotherapy" or SRT is being considered (based on requested billing codes). The American Academy of Dermatology released separate statements for electronic brachytherapy and superficial radiation, with similar concerns about both modalities. These statements specifically state that surgical management is the most effective treatment providing the highest cure rate and that electronic brachytherapy or superficial radiation can be considered for "special circumstances" in which surgical resection is contraindicated (no such information is provided in this case). It also states that long-term outcomes are needed to for electronic brachytherapy and superficial radiation. Like ASTRO, it describes the need for specific training in this modality, and need to comply with federal and state laws. This statement also expresses concerns about potential over-utilization and abuse.Based on this information and the lack of clear demonstration of the need for superficial radiation therapy over resection or EDC, the use of this treatment would not fall within the accepted standards of medical practice. 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 requested radiation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvelow-dose radiation therapy for multiple skin cancer sites.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethree repeat medial branch block injections for the enrollee.You asked the Plan to pre-approvethe repeat injections. You say that this is medically necessary.The Plan denied your request. The Plan says two injections can be approved, but the third exceeds the Medicare limit.The Plan must follow Medicare rules. Medicare rules say that two diagnostic injections are allowed per session, per region. The plan decided to overturn and approve the first two levels of this injection. Two levels is the maximum allowed per session. The third level cannot be approved, as it exceeds the Medicare limit. Based on this information, we decided that Medicare rules for coverage of the third level of injection have not been met.Therefore, we decided that the Plan does not have to pre-approvethe third level of medial branch block injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla.
You asked the Plan to pre-approve Otezla. 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 Otezla.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor provided
on April 3, 2020.
You asked the Plan to waive the coinsurance for the continuous glucose monitor. You say that diabetic testing
supplies should not have a copay. The Plan denied your request. The Plan says that the claim processed
correctly.
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 20%
coinsurance for durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for the continuous glucose monitor. The continuous glucose
monitor falls within the durable medical equipment (DME) and related 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 coinsurance for the continuous glucose monitor provided on April 3, 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.
You asked the Plan to pre-approve IRF care. You say that it is felt that intensive therapy would be best in this
case. The Plan denied your request. The Plan says the enrollee's needs can be met in 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 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 enrollee is a female who presented to the hospital on 7/10/2020 with dislocation
of her right hip prosthesis. She had reduction of the dislocation in the emergency department and is now in a
Newport brace. She is weight bearing as tolerated and is working with physical and occupational therapy. She
is cooperative with therapy but she has impulsivity and decreased insight into her deficits.
Based on the medical records provided, 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 does require physical therapy and occupational therapy services but does not require an intensive
inpatient rehabilitation therapy program. There is also concern that the patient will not be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor supplies.
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that these are medically
necessary for you. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies 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. Based on this
information, we decided that Medicare rules for coverage of continuous glucose monitor supplies have not
been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor
supplies.