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

We decided that the Plan has to pre-approve 2 epidural steroid injections. We decided that the Plan does not have to pre-approve the remaining 2 epidural steroid injections.
You asked the Plan to pre-approve a total of 4 epidural steroid injections. You say that the 4 requested epidural steroid injections are medically necessary. The Plan says that the enrollee does not meet criteria.
We decided that the Plan has to pre-approve 2 epidural steroid injections.
The Plan must follow Medicare rules. The rules say no more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally). 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 of 4 epidural steroid injections. Our reviewer says that the enrollee meets criteria for 2 epidural steroid injections. Our physician reviewer found the enrollee has chronic knee and back pain. She takes Zanaflex, Gabapentin and Oxycodone for pain. She has had trials of physical therapy, Chiropractic and a Home exercise program. She has also tried NSAIDs. The request is for 2 levels bilaterally of transforminal epidural steroid injection (4 injections total). This request exceeds utilization guidelines. Therefore, only 2 injection sites are medically reasonable and 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 2 epidural steroid injections have been met. Therefore, we decided that the Plan has to pre-approve 2 epidural steroid injections.
We also decided that the Plan does not have to pre-approve the remaining 2 epidural steroid injections.
The Plan must follow Medicare rules. The rules say no more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally). Based on this information, we decided that Medicare rules for coverage of the remaining 2 epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 2 epidural steroid injections.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that your primary care physician referred you. The
Plan denied your request. The Plan says there are in-network providers available for 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 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
an office visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.
You asked the Plan to pre-approve these services. You say that you are in pain and not able to eat. The Plan
denied your request. The Plan says the services are not covered.
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
complete upper and lower dentures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital admission.
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 pre-approve acute inpatient hospital admission. Our reviewer says that the documentation does not support that inpatient admission is medically necessary. Our physician reviewer found the records do not show that the admitting physician reasonably expected the enrollee's necessary hospital 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 admission have not been met. Specifically, there is no indication the enrollee's care would span two midnights. This means admission to an acute inpatient hospital is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective outer surface covering (L5962) for a lower
limb prosthesis.
You asked the Plan to pre-approve the protective outer surface covering. You say that the specialty covering is
medically necessary. The Plan denied your request. The Plan says the records do not support the requested
covering.
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems are
specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has
special needs for protection against unusually harsh environmental situations where it is necessary to protect
the lower limb prosthesis.
We looked at the file and Medicare rules. The record does not include any documentation of the enrollee
having a need to use the prosthesis in an unusually harsh environment or situation. Based on this information,
we decided that Medicare rules for coverage of the protective outer surface covering have not been met.
Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering (L5962)
for a lower limb prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical procedures for isolation of tooth with rubber dams (D3910 x2), two canal preparations and fittings of preformed dowels or posts (D3950 x2), and drugs or medicaments dispensed in the office for home use (D9630).
You asked the Plan to pre-approve the surgical procedures for isolation of tooth, canal preparations and fittings, and drugs or medicaments. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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, 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 two surgical procedures for isolation of tooth with rubber dams (D3910 x2), two canal preparations and fittings of preformed dowels or posts (D3950 x2), and drugs or medicaments 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 a commode chair.
You asked the Plan to pre-approve a commode chair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested commode chair.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a commode chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-home hearing test and assessment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the hearing services. You say that the enrollee is unable to walk to a car for transport to provider office and cannot stand. You are concerned that the enrollee will be injured with just getting him to a vehicle to transport. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 an in-home hearing test and assessment 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 pay the in-network rate for the unspecified preventive service (D1999) provided on February 25, 2021.
You asked the Plan to pay the in-network rate for the unspecified preventive services. You say that you found this provider on the plan's website. You also say that you should not have to pay for these services. The Plan denied your request. The Plan says unspecified preventive service 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 unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in-network rate for the unspecified preventive service (D1999) provided on February 25, 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 the enrollee would benefit from IRF due to the ability to progress in therapy and the need for 3 therapy types. 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 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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
While the enrollee does require physical and occupational therapy, 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 the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit represented by code 99285 provided on September 10, 2020.
You asked the Plan to pay for code 99285. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. The file shows that the Plan had previously paid
for code 99285 on a different claim with the same enrollee, date of service, and provider. Therefore, we decided that the Plan does not have to pay for the emergency department visit represented by code 99285 provided on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray you had on January 22,
2021.
You asked the Plan to waive the copayment for the chest x-ray. You say that no one told you there would be a
copayment for this service. The Plan denied your request. The Plan says you were charged this copayment
correctly.
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 $15
copayment for x-rays.
You have been asked to pay a $15 copayment for the chest x-ray. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the chest x-ray you had on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on November 13, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on November 13, 2020. The total allowed amount is $72.84 and 20% of that is $14.57. You have been asked to pay the total coinsurance amount of $14.57 for Medicare Part B drugs. Medicare Part B drugs fall 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 coinsurance for Medicare Part B drugs provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure you had at an outpatient hospital clinic on March 2, 2021.
You asked the Plan to waive the copayment for the injection procedure. You say that you disagree with this cost sharing. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount is less than your copayment obligation, you are responsible for the full amount.
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 $275 copayment for services at an outpatient hospital facility. You have been asked to pay a $275 copayment for the injection procedure. The injection procedure falls within the services at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection procedure you had at an outpatient hospital clinic on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the enteral nutrition provided from January 1, 2021, to February 13, 2021.
You asked the Plan to pay for the home infusion therapy and waive the copayment for the enteral nutrition. You say that any services provided by the home health agency should be covered. The Plan denied your request. The Plan says you were charged the coinsurance correctly.
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 4% coinsurance for prosthetic devices and related supplies.
You have been asked to pay 4% coinsurance for the enteral nutrition. The enteral nutrition falls within the Prosthetic Devices and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the enteral nutrition provided from January 1, 2021, to February 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 29, 2021.
You asked the Plan to pay for the ambulance services. You say that you requested a lift assist. 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 29, 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 29,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (K0554) and supplies (K0553).
You asked the Plan to pre-approve continuous glucose monitor and supplies. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for a continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (K0554) and supplies (K0553).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the breast ultrasound you had on
September 23, 2020, and the chest x-ray you had on October 22, 2020.
You asked the Plan to waive the copayments for the ultrasound and the x-ray. You say that the provider
ordered multiple procedures on one script. You believe you should only have one copayment. The Plan denied
your request. The Plan says you were charged these copayments correctly.
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 $30
copayment for x-rays and a $155 copayment for radiological diagnostic services.
You have been asked to pay a $155 copayment for the ultrasound and a $30 copayment the x-ray. 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 copayments for the breast ultrasound you had on September 23, 2020, and the chest
x-ray you had on October 22, 2020.