Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and
occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.You asked the Plan to pre-approve a PET scan of the brain. 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 follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD.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 PET scan of the brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found there was no indication within the records provided that the member met/meets diagnostic criteria for both AD and FTD. Rather, there was nothing in the records provided for review to suggest a diagnosis of FTD. Furthermore, there were other potential causes of dementia noted in both the records and the neuropsychology summary.
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 PET scan of the brain have not been met.Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on January 12, 2021, and March 15, 2021, by an in-network provider.You asked the Plan to waive the coinsurance for the DME. You say that your provider wants to change mask once a month and other parts of the breathing machine.The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 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 the filter (Current Procedural Terminology (CPT) code A7038NU), headgear used with positive airway pressure device (CPT code A7035NU), and water chamber for humidifier, used with positive airway pressure device, replacement (CPT code A7046NU) on January 12, 2021. You have been asked to pay 20% coinsurance of the allowed amount for the DME. The allowed amount for this date of service is $35.17. The total you owe for January 12, 2021, is $7.03 ($35.17 x 20% = $7.03). Furthermore, the file show that you received the filter (CPT code A7038NU), face mask interface (CPT code A7031NU) and tubing with integrated heating element for use with positive airway pressure device (CPT code A4604NU) on March 15, 2021. You have been asked to pay 20% coinsurance of the allowed amount for the DME. The allowed amount for this date of service is $76.52. The total you owe for March 15, 2021, is $15.30 ($76.52 x 20% = $15.30). Your total cost share responsibility is $22.33 ($15.30 + $7.03 = $22.33). Your 2021 EOC states that enrollees must pay 20% of the total allowed amount for in-network Medicare-covered DME and related supplies. 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 DME provided on January 12, 2021, and March 15, 2021, by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance (E0669) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the specific device is only available from the requested provider. The Plan denied your request. The Plan says this is available in-network.

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 pneumatic compression device (E0652) and appliance (E0669) 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 a gingival flap procedure with root planing (D4240).You asked the Plan to pre-approve the gingival procedure. You say that this procedure is medically necessary.The Plan denied your request. The Plan says this service is not covered by the Plan's dental 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.
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 a gingival flap procedure with root planing (D4240).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for inpatient mental health care provided from January 9, 2021, through January 20, 2021.

You asked the Plan to waive the co-payment for inpatient mental health care. You say that you were admitted involuntarily, and the hospital did not provide you with cost-share information. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance).

Review of the file shows that you were admitted on January 9, 2021, and discharged on January 20, 2021. You were asked to pay a $365 co-payment per day from January 9, 2021, through January 12, 2021, days 1-4 of your inpatient mental health stay. There were no co-payment charges from January 13, 2021, day 5 of your inpatient hospital care until your day of discharge January 20, 2021. Per your contract there is a $365 co-payment per day required for days 1-4. 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 co-payment for inpatient mental health care provided from January 9, 2021, through January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950) for tooth #20.

You asked the Plan to pre-approve a core buildup. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by the Plan's dental 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. 

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 a core buildup (D2950) for tooth #20.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 22, 2021.

You asked the Plan to pay for the ambulance services. You say that your husband needed assistance from the
medics to get into bed from falling. The Plan denied your request. The Plan says these services are not a
covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on January 22, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 22,
2021.
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 have fallen three times and need to get stronger. You have no one to help you at home and you do not feel it is best for you to go home without some sort of rehab. The Plan denied your request. The Plan says you do not require an intensive program with a team of healthcare professionals for complex medical needs and rehabilitation. An IRF is not 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 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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with interdisciplinary approach to rehabilitation care. Your medical conditions are stable. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture with a flexible base (D5226), an
alveoloplasty (D7311) and drugs dispensed in the office for home use (D9630).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan
denied your request. The Plan says these services are not covered by your dental 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.

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 a
partial lower denture with a flexible base (D5226), an alveoloplasty (D7311) and drugs dispensed in the office
for home use (D9630).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued use of a CPAP device.
You asked the Plan to pre-approve the continued use of a CPAP device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says there is no evidence of compliance and adherence to therapy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued use of a CPAP device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have been unable to use the device enough for it to be effective, and to meet minimum Medicare criteria of at least 4 hrs/day for at least 70% of days. 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 continued use of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a CPAP device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial upper denture (D5820).You asked the Plan to pre-approve the dental item. You say that you thought partial dentures were covered. You say that you have not used your dental benefit this year. You also say that you do not understand why the service is not covered.The Plan denied your request. The Plan says interim partial upper denture is not listed as a covered service.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 pre-approve an interim partial upper denture (D5820).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint injections (64493, 64495, 64494).You asked the Plan to pre-approve the facet joint injections. You say that the requested services are medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when 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 facet joint injections. Our reviewer says that the requested services are medically necessary. Our physician reviewer found the indication for Monitored Anesthesia Care in this patient is Morbid Obesity. The patient achieved 90% pain relief from the first set of blocks. Additional blocks 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 the facet joint injections have been met.Therefore, we decided that the Plan has to pre-approve facet joint injections (64493, 64495, 64494).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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ezetimibe.You asked the Plan to pre-approve Ezetimibe. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 Ezetimibe.Benefits for Ezetimibe 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery.

You asked the Plan to pre-approve the bariatric surgery. You say that it is felt that this treatment is medically needed to manage the enrollee's obesity. The Plan denied your request. The Plan says there is no documentation of weight loss management being attempted.

The Plan follows Medicare rules. Medicare rules say that bariatric surgery may be considered reasonable and necessary for enrollees who meet certain criteria and have been previously unsuccessful with medical treatment for obesity.

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 bariatric surgery. Our reviewer says that the records do not support the medical necessity of this surgical intervention. Our physician reviewer found the record indicates that the enrollee has a BMI of 38, diabetes, and hypertension. The record does not support that the enrollee has been previously unsuccessful with medical treatment for obesity. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended at this time.

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 bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve bariatric surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional office visits with an out-of-network provider.

You asked the Plan to pre-approve the office visits. The Plan denied your request. The Plan says the services are available in-network.

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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve four additional office visits with an out-of-network provider.