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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 10, 2018 through September 11, 2018.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 10, 2018 through September 11, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150), panoramic radiographic image (D0330), bitewings - four radiographic images (D0274), core buildup, including any pins when required (D2950) and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on December 3, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were informed by the dental plan that you had two dental plans. The Plan denied your request. The Plan says you are responsible for deductible and coinsurance.
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 received comprehensive oral evaluation - new or established patient (D0150), panoramic radiographic image (D0330), bitewings - four radiographic images (D0274), core buildup, including any pins when required (D2950) and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on December 3, 2019 by an out-of-network provider. The claim was processed correctly according to plan benefits. What is not covered under the plan, will be subjected to the Platinum Dental Rider. When selecting an out-of-network provider the providers are paid based on Maximum Allowable Charge (MAC). You may be billed by the out-of-network provider for any amount greater than the payment made by the plan to the provider or any services not covered by the plan.
The Platinum Dental Rider does have a deductible of $100.00 which doesn't apply to exams, bitewings, all x-ray services, cleanings, or fluoride. Also, an Annual Maximum of $1000.00 that the plan will pay up to, after the annual maximum is exhausted; any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150), panoramic radiographic image (D0330), bitewings - four radiographic images (D0274), core buildup, including any pins when required (D2950) and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on December 3, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 has network providers available who can provide the items/services at issue in this appeal. 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 lab services provided on January 31, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OZURDEX (J7312).
You asked the Plan to pre-approve the OZURDEX. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says off-label use of this drug is not medically accepted per Medicare rules.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 OZURDEX. Our reviewer says that the requested use of OZURDEX injections is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found the use of OZURDEX injections for the diagnosis of combined inflammatory macular edema following cataract surgery/focal chorioretinal inflammation, macular or paramacular, right eye is not indicated or supported or recommended in any of the compendia. 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 OZURDEX have not been met. Therefore, we decided that the Plan does not have to pre-approve OZURDEX (J7312).
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 you required moderate independent for upper body dressing. The enrollee required stand-by assistance for bed mobility, supine to sit, and rolling. You required minimal assistance with platform walker and wheelchair follow through. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. While you may benefit from multiple therapies such as physical and occupational therapy, the documentation does not support that you require an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the SI joint for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says medical research articles have not shown that the use of this kind of treatment improves outcomes.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental and investigational therapy because of the wide variation in efficacy in the peer-reviewed literature. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the SI joint for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the gym membership for April 17, 2019.
You asked the Plan to reimburse for the gym membership. You say that you did not use the wellness allowance reimbursement for your gym membership in 2019. You state that you should get reimbursed for the $150. The Plan denied your request. The Plan says it was determined that the reimbursement benefit was applied correctly. The Plan states they have already paid the maximum Wellness Allowance amount for this benefit. The Plan states you can submit the wellness allowance benefit reimbursement form with proof of paid receipts several times until you have received up to $150, and the deadline for the benefit limit is by March 31st of the following year.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan has already paid the maximum Wellness Allowance amount for this benefit. Therefore, we decided that the Plan does not have to reimburse for the gym membership for April 17, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services, and the inpatient hospital care provided January 4, 2020 to January 12, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that Original Medicare is responsible for payment of all Medicare-covered services provided.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 9, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the emergency room services, and the inpatient hospital care provided January 4, 2020 to January 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the mandibular partial denture received on March 5, 2020.
You asked the Plan to pay for the mandibular partial denture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the benefits are not payable for prosthesis replacing teeth lost prior to the effective date of coverage.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules also 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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the plan has denied the denture due to prosthesis replacing teeth lost prior to the effective date of coverage. The documentation did not include any evidence of when the teeth were pulled prior to the effective date of coverage. You provided documentation stating that these teeth were pulled in 2019. The plan did not provide evidence of when your dental coverage started after the teeth were pulled. In addition, you were provided the dentures by a contract provider. The file does not show that the Plan provided notice that the denture would not be covered. Under Medicare rules, this means the denture is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the mandibular partial denture received on March 5, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair (E1399) and a seat lift mechanism (E0627). You asked the Plan to pre-approve a recliner chair and a seat lift mechanism. You say that a lift chair is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a lift chair.The Plan must follow Medicare rules. The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. The rules also say that a seat lift mechanism is covered if all of the conditions listed are met.We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a recliner chair and seat lift mechanism have not been met.Specifically, a recliner chair is not durable medical equipment that is mainly used to serve a medical purpose. Additionally, the medical records provided do not indicate that you have severe arthritis of the hip or knee or have a severe neuromuscular disease. The record is not clear that you are completely incapable of standing from a chair in your home.
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 supervision for eating, grooming, upper and lower body dressing, bed mobility, sit to stand, transfers, and walking 15 feet with a wheeled walker. The documentation does not support that the enrollee requires 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 endurance level can tolerate an intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on January 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 has network providers available who can provide the items/services at issue in this appeal. 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 an outpatient visit provided on January 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on March 2, 2020.You asked the Plan to pay for the ophthalmological services. You say that you have been going to this provider for eight years and only had to pay your copayment. You say that your Plan paid this provider for eight years and should pay this claim. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization fromthe plan.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 careand pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the ophthalmological services. 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 ophthalmological services provided on March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve T12 vertebroplasty for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is needed due to recent MRI results demonstrating an acute T12 compression fracture. The Plan denied your request. The Plan says the requested procedure is not indicated at this time.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a trial and failure of conservative measures for for the treatment of back pain from compression fractures. More conservative measures are needed. Kyphoplasty is not indicated now. The recent literature does not support kyphoplasty. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve T12 vertebroplasty for the enrollee.
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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point appear to be 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 skilled nursing facility (SNF) care.