Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the preventive exam provided to you on January 22, 2020.
You asked the Plan to pay for the exam. The Plan denied your request. The Plan says that Medicare does not cover preventive exams.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided the preventive exam by a contract provider. The file does not show that the Plan provided notice that the exam would not be covered. You have no control over how the provider codes and bills the visit. Under Medicare rules, this means the exam is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the preventive exam provided to you on January 22, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has monoclonal gammopathy
of undetermined significance (MGUS) diagnosed in 2011 with concern of progression to multiple myeloma.
PET scans are indicated for the initial work-up of multiple myeloma. There is suspicion for multiple myeloma
based on new onset stroke and significant elevation in urine paraprotein. The National Comprehensive Cancer
Network (NCCN) guidelines recommend PET scan for work-up for this condition. The services are 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 been met. Therefore, we decided that the Plan has to preapprove
a positron emission tomography (PET) scan.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 required minimal assistance to maximum assistance with activities of daily living and functional activities of daily living. 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: Favorable

We decided that the Plan has to pre-approvestereotactic body radiation therapy (SBRT).You asked the Plan to pre-approveSBRT. You say that SBRT is required for the enrollee as it would give a high probability of local control with acceptable low risk of significant toxicity to the organs.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the records do not include necessary documentation to support the need for service.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be coveredwhen it is 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 SBRT. Our reviewer says that the enrollee meets the Medicare criteria for the requested SBRT. Our physician reviewer found while this is an uncommon clinical situation, and the ability to establish medical necessity based on robust data is challenging, SBRT for 2 to 3 discrete metastases is an accepted standard of care. The advantages of SBRT are to allow dose escalation while minimizing the volume of normal tissues exposed to high dose radiation. These principles coupled with the medically standard application of SBRT to oligometastatis sites would mean that medical necessity criteria are met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have been met.Therefore, we decided that the Plan has to pre-approvestereotactic body radiation therapy (SBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network provider.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 requestedprovider 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-approvean office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional removal of teeth.
You asked the Plan to pre-approve additional removal of teeth. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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. Review of the file shows that you requested for teeth extractions of teeth 23, 27, and 28. The plan previously were approved for the removal of teeth 21 and 22. Since your plan only covers 2 extractions per year, the plan does not have to approved any additional teeth extractions. 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 pre-approve additional removal of teeth.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Efudex Cream.
You asked the Plan to pre-approve Efudex Cream. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Efudex Cream is not covered under the enrollee's Medicare Part B 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 Efudex Cream.
Benefits for Efudex Cream 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 pay for skilled nursing services provided on February 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 skilled nursing stay was not covered past January 22, 2020; therefore, prior authorization is required for these services. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on February 20, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot feature, rotational unit.
You asked the Plan to pre-approve Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and All lower extremity prostheses, flex-walk system or equal (L5981). You say that you need these components. The Plan denied your request. The Plan says the requested components exceed your needs.
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 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and All lower extremity prostheses, flex-walk system or equal (L5981). Our reviewer says that the requested items are not considered medically
reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee meets the requirement for Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and All lower extremity prostheses, flex-walk system or equal (L5981) per Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) and Lower Limb Prostheses - Policy Article (A52496). The physician medical notes do not support that this enrollee will require advanced functional features for ambulation such a multiaxial ankle and features in the requested L5968 and the flex walk type system. There is no evidence that this enrollee has vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. The enrollee refused to participate in questions on activity and transportation in the physician progress note. The documentation does not support the requested items. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and All lower extremity prostheses, flex-walk system or equal (L5981) have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot feature, rotational unit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 19, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to change dentists. You also say that going to the dentist is not a pleasant thing to do, and you expect to be treated in a way that makes you feel more comfortable. The Plan denied your request. The Plan says this service exceeds the frequency limitation in the benefit 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on October 1, 2018, and your comprehensive oral evaluation has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 19, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit (99283) provided March 19, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment 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 $90 copayment for Emergency Care. You have been asked to pay a $90 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 foran emergency room visit (99283) provided March 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided February 7, 2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary and billed correctly. The Plan denied your request. The Plan says the services were billed with an invalid place of service. 
 
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 90832 is not supported in the medical record. Specifically, the claim for outpatient services was billed using an inpatient place of service. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided February 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to a SNF.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee suffered a spinal cord injury in May 2019 with T10 paraplegia, complicated by hardware infection requiring prolonged hospitalization and antibiotics (6 months). He presented to the emergency room on 7/7/20 with a complaint of headache and difficulties caring for himself at home. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had uncomplicated wound care to his sacrum. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was ata maximal assist level for bed mobility and required a mechanical lift for transfers. The beneficiary required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis.  This enrollee does not meet severity of illness or intensity of service criteria for 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 17, 2019. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. 
 
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. The medical records do not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral orthosis provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on October 25, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that the orthosis was medically necessary.The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.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. The medical records do not mention or support medical necessity for the orthosisat issue. The medical records of September 10, 2019 mention that the enrollee already wears a brace for support. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on October 25, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leukine.
You asked the Plan to pre-approve Leukine. The Plan denied your request. The Plan says claims for routine
costs associated with a clinical trial are not payable by the Part B plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve Leukine as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
Leukine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the services from January 31, 2020 through March 12, 2020 provided by multiple providers.
You asked the Plan to waive the cost-share for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received urgent care services provided on January 31, 2020. You are asked to pay a $55 copayment for the urgent care visit.
Review of the file shows that you were admitted on February 5, 2020 and discharged on February 9, 2020. You were asked to pay a $375 copayment per day from February 5, 2020 through February 8, 2020, days 1-4 of your inpatient hospital care. You were discharged on February 9, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $375 copayment per day required for days 1-5 for in-network inpatient hospital care. On February 9, 2020 you received an oxygen concentrator rental from an in-network provider. You are asked to pay 20% coinsurance. You received office services on February 14, 2020 from an in-network provider. You are asked to pay a $20 copayment for an office visit with a PCP. You received a chest x-ray om February 14, 2020 from an in-network provider. You are asked to pay a $35 copayment for the x-ray. Furthermore, you received laboratory services on March 12, 2020 from an in-network provider. The Medicare-allowed amount for the laboratory services is less than the set $20 copayment; therefore, you have been asked to pay the lesser amount of $9.47 for the in-network laboratory services. 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 cost-share for the services from January 31, 2020 through March 12, 2020 provided by multiple providers.