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 inpatient rehabilitation is medically necessary, and
the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the
criteria for IRF care are not met. The enrollee's conditions are chronic and stable, and their rehabilitation needs
are not complex. The necessary care can be provided 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does require physical and occupational therapy, but there is no documented need for an intensive
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 31, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested item is 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 a lumbar-sacral orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that an appropriate history and a physical examination of the back would reasonably be
required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The
documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered
indications in this case, as there is insufficient documentation of a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan
does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the three surgical extractions provided on March 1, 2021 by an OON provider.
You asked the Plan to pay more for the extractions. You say that it seems like the Plan would rather not pay for the three extractions, which were abscessed and making you very sick. The Plan denied your request. The Plan says you are responsible for any difference between the maximum allowable fee and the amount the provider bills you for the 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 55% coinsurance for each extraction, plus the difference between the billed amount and the amount that was paid by the Plan for services received OON. Therefore, we decided that the Plan does not have to pay more for the three surgical extractions provided on March 1, 2021 by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on January 20, 2021.
You asked the Plan to pay for the psychotherapy visit. You say that the enrollee has out of network benefits. The Plan denied your request. The Plan says the service is not a covered benefit
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently attempt to enroll in Medicare but are not eligible to do so. A Certified Social Worker is not eligible to enroll in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy visit have been met. The record shows this provider is a Licensed Clinical Social Worker (LCSW). LCSWs are not eligible to enroll in Medicare which means this provider is not payable. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate for use as bone graft in spinal surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs more therapy and would benefit from family presence during her therapy to ensure she completes it. You feel that SNF care should be allowed to help her make more progress. The Plan denied your request. The Plan says the enrollee's condition is not likely to benefit from daily skilled services in the SNF setting. Also, at this time, her needs are being met in the current 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with kidney disease receiving dialysis who was admitted to the hospital on 6/29/2021 after waking up with left arm hemiparesis. She was found to have right carotid stenosis and evidence of recent lacunar strokes. She was discharged to an inpatient rehabilitation facility for therapy and is now requesting to be transferred to a SNF for further care. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF on a daily basis. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen 10-325 mg.
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that this is medically necessary to
treat the enrollee's lumbar pain. The Plan denied your request. The Plan says this drug is not 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 selfadministered
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 Hydrocodone-
Acetaminophen 10-325 mg.
Benefits for Hydrocodone-Acetaminophen 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 pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided August 11, 2020.
You asked the Plan to pay for the orthoses. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this provider conducts unsolicited outreach calls to enrollee's. The documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have
not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and
suspension sleeve (L2397) provided August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging, (MRI) of left hip and
knee (73720, 73721).
You asked the Plan to pre-approve the MRI. You say that the records should support the necessity of the
service billed. The Plan denied your request. The Plan says the records do not support that the requested
services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that the enrollee has a several weeks history of knee and hip pain after
heavy lifting. The provided records do not document a physical examination physical therapy has not been
attempted. The record does not indicate a reevaluation has been performed. The record does not support the
medical necessity or reasonableness, as defined by Medicare rules, of the requested service.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve the magnetic resonance imaging, (MRI) of left hip and knee (73720, 73721).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planning (D4341), and an adjunctive pre-diagnostic test (D0431) provided on April 1, 2021.
You asked the Plan to pay for periodontal scaling and root planning, and an adjunctive pre-diagnostic test. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 periodontal scaling and root planning (D4341), and an adjunctive pre-diagnostic test (D0431) provided on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee no longer requires daily skilled nursing and/or skilled therapy services. He could benefit from continued intermittent services at a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services provided by participating provider on September 18, 2020.
You asked the Plan to waive the copayment for radiology services. You say that you do not agree with this copayment. 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 $150 copayment for outpatient diagnostic tests/complex diagnostic radiology. You have been asked to pay a $150 copayment for radiology services. The correct copayment has been applied to the MRI that was provided. Radiology services fall within the outpatient diagnostic tests/complex diagnostic radiology 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 radiology services provided by a participating provider on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the drug testing services provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 18, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 18,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay provided April 1, 2021 to April 14, 2021.
You asked the Plan to waive the copayment for the SNF days. You say that you feel that you were misled by the nursing home because you were told you were covered and was showed a letter stating that your stay was covered. If you had known it was not covered in full, you would not have stayed. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $0 copayment per day for SNF days 1-20, $185 copayment per day for SNF days 21-100.
You have been asked to pay $920 ($185 x 5 days) for the SNF stay. The SNF stay falls within the skilled
nursing facility (SNF) 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 the skilled
nursing facility (SNF) stay provided April 1, 2021 to April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses provided to the enrollee on March 30, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that durable medical equipment generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We find that the denied codes are not supported in the medical record. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of these orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses provided to the enrollee on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composites provided on April 19, 2021.
You asked the Plan to pay more for the resin-based composites. You say that you were told fillings are paid at 100% when you bought the enhanced dental. The Plan denied your request. The Plan says the supplemental dental benefit allows coverage of fillings based on the cost for amalgam material. The Plan also says that you are responsible for the difference in cost of the white material.
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 Plan will only pay the amount to restore a posterior tooth with amalgam. You are responsible for the difference in cost of the amalgam and resin restoration. Therefore, we decided that the Plan does not have to pay more for the resin-based composites provided on April 19, 2021.