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

We decided that the Plan does not have to pay for the skilled nursing services provided from April 18, 2019 to May 17, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from December 31, 2018 to April 17, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from April 18, 2019 to May 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation and extraction.
You asked the Plan to pre-approve dental consultation and extraction. You say that if your tooth keeps losing pieces, you are at risk of needing a more significant surgery with more health risks. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because dental services provided by an oral surgeon are not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Please contact the Plan for more information about covered dental providers who may be able to treat you. Therefore, we decided that the Plan does not have to pre-approve a dental consultation and extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 27, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on June 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite, 1 surface, anterior (D2330), the resin based composite, 1 surface, posterior (D2391 x 2), and the application of desensitizing medicament (D9910) provided on September 24, 2019. You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental services you received are not covered 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, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin based composite, 1 surface, anterior (D2330), the resin based composite, 1 surface, posterior (D2391 x 2), and the application of desensitizing medicament (D9910) provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 13, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that 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 emergency situation, 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 services 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 a drug test provided on September 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for organic acid lab services (83921) provided to the enrollee on August 1, 2019.
You asked the Plan to pay for organic acid lab services. You say that the provided services were medically necessary. The Plan denied your request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.
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 organic acid lab services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the provided documentation, MMA (methylmalonic acid) levels were ordered and resulted which is typically ordered in the setting of clinical situations where severe vitamin B12 deficiency is suspected. In this case, vitamin B12 levels ordered at the same time were equivocal, however, the clinical situation was not described in the provided records to help support the MMA testing. Therefore, without sufficient support made for this request the organic acid, single, quantitative testing (MMA) 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 organic acid lab services have not been met. Therefore, we decided that the Plan does not have to pay for organic acid lab services (83921) provided to the enrollee on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services and coinsurance for an injection provided on October 11, 2019.
You asked the Plan to waive the copayment for outpatient hospital services and coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $290 copayment and a 20% coinsurance for outpatient hospital services/most outpatient hospital services and Medicare Part B prescription drugs. You have been asked to pay a $290 copayment for outpatient hospital services and a 20% coinsurance of the allowed amount for an injection. The allowed amount for the injection is $1,223.80. The amount you are being asked to pay for the injection is $244.76 ($1,223.80 x 20% = $244.76). The total amount you are being asked to pay is $534.76 ($290 + $244.76 = $534.76). Outpatient hospital services falls within the outpatient hospital services/most outpatient hospital services and an injection falls within the Medicare Part B prescription drugs 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 outpatient hospital services and coinsurance for an injection provided on October 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroplasty at the inpatient level of care.
You asked the Plan to pre-approve a total knee arthroplasty at the inpatient level of care. You say that the records provided support the need for the inpatient level of care being requested. The Plan denied your request. The Plan says the procedure could be safely provided in a hospital observation setting because the enrollee does not have any comorbidity conditions that would require the procedure to be done at an inpatient level of care setting.
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 a total knee arthroplasty at the inpatient level of care. Our reviewer says that an inpatient admission is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show sufficient medical reason for inpatient admission after total joint surgery. The procedure could be done safely with an observational stay. 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 total knee arthroplasty at the inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty at the inpatient level of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve 90 additional routine transports for the enrollee.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee has exhausted the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year. We looked at the request, the records in the case file, and the rules. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of these services. Therefore, we decided that the Plan does not have to approve 90 additional routine transports for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on October 17, 2019.
You asked the Plan to pay for the dental services. You say that your appointment you had for a second opinion. You say that it was not for a periodic oral evaluation. The Plan denied your request. The Plan says the frequency limit has been exceeded.
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 and oral evaluations are a covered service, the frequency limit has been reached. The record shows that the Plan previously paid for oral evaluations that you received on April 12, 2019 and May 30, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot drop splint, recumbent positioning devices.
You asked the Plan to pre-approve foot drop splint, recumbent positioning devices (L4398). You say that the enrollee does not walk but does need foot drop splints to stand in a frame. The Plan denied your request. The Plan says foot drop splints are not covered by Medicare nor the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of foot drop splint, recumbent positioning devices (L4398) have not been met. Therefore, we decided that the Plan does not have to pre-approve foot drop splint, recumbent positioning devices.
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 enrollee had many falls prior to being hospitalized and is still requiring increased cues and supervision for safely. The Plan denied your request. The Plan says the enrollee has only had a slight decline from baseline activities of daily living. The Plan says that the intensive and comprehensive therapies at an IRF are not medically necessary. The Plan says that they would approve an admission to a skilled nursing facility for strengthening, balance, and to reduce the risk of falls.
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 skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on June 17, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Plan representative told you that this provider was in-network with your plan when you enrolled. The Plan denied your request. The Plan says these services are only covered when they are received by your selected primary care dentist. The Plan also says that they confirmed that there were no contacts from you prior to the services to select a network primary care dentist.
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 when they are received by a dentist other than your network primary dentist. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you would like to see any cardiologist at this hospital. The Plan denied your request. The Plan says there are network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
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 you are appealing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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, complex medical or nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication management, wound care, and daily therapy can be provided at a SNF. In this case a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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 knee orthosis (L1843).You asked the Plan to pre-approve the knee orthosis. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the knee orthosis.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 knee orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not show that the beneficiary had a recent knee injury or surgery. The record also does not show that the member is ambulatory with knee instability due to a covered condition. Additionally, the documentation submitted does not support that the member's knee instability has been documented by examination of the member and objective joint laxity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve knee orthosis (L1843).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says it is more appropriate for the enrollee to remain at the current inpatient hospital.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different thanthose of short term acute care hospitals. In this case, ongoing care needs include respiratory support including intermittent BiPAP, nebulizer treatments, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.  Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including intermittent BiPAP, nebulizer treatments, surveillance laboratory studies, tube feedings, and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care.There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician'sreview, 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-approveadmission to a long term acute care hospital (LTACH) for the enrollee.