Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) and unspecified preventive procedure, by report (D1999) provided December 21, 2020.
You asked the Plan to pay for the bitewing x-rays and unspecified preventative procedure. You say that the services should be covered because you required additional x-rays due to needing a second opinion and failure of the original provider to forward x-rays to the provider of the services at issue. The Plan denied your request. The Plan says you have already had one set of bitewing x-rays covered in the past 12 months therefore the x-rays at issue are not covered. The Plan also says that unspecified preventive procedures are not covered under 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. The Plan covers the bitewing x-rays once every 12 months.
We looked at the file and Medicare rules. The record shows that you previously had bitewing x-rays covered once within 12 months of the requested service. Therefore, the bitewing x-rays provided December 21, 2020 are not covered. Additionally, unspecified preventative procedures are not covered services under your dental benefit. Based on this information, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) and unspecified preventive procedure, by report (D1999) provided December 21, 2020.
Your complaint about requiring a second opinion resulting in additional x-rays beyond the Plan's limit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade.
You asked the Plan to pre-approve Remicade. You say that this request is medically necessary. The Plan denied
your request. The Plan says it is unknown if Remicade will be used in combination with Methotrexate and
unknown if there has been at least a 20% improvement in tender and swollen joint count.
The Plan follows Medicare rules. Medicare rules say that the documentation must clearly document at least
20% improvement in tender joint count and at least 20% improvement in swollen joint count.
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 Remicade. Our reviewer says that the
requested drug does not meet the relevant coverage criteria. Our physician reviewer found the enrollee is a 77-
year-old woman with a diagnosis of Rheumatoid arthritis with rheumatoid factor of multiple sites without
organ or systems involvement. Although the requested drug is medically reasonable and necessary for the
enrollee, the documentation in the medical record does not clearly document at least 20% improvement in
tender joint count and at least 20% improvement in swollen joint count for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have
to pre-approve Remicade.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar decompression surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the ECG provided on September 28, 2020.
You asked the Plan to waive the copayment the ECG. You say that this was a routine ECG and there should not be a charge. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $20 copayment for in-network Medicare-covered non-radiological diagnostic services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $20 copayment for the ECG.
You have been asked to pay a $17.04 copayment for the ECG. The ECG falls within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 the ECG provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON cardiology services. You say that you have had this provider recommended and feel it should be covered. The Plan denied your request. The Plan says there is no medical reason given for the need of an OON cardiologist. The network has many cardiologists able to treat your condition.
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 cardiology services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. 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 medically necessary.
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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a history of ischemic cardiomyopathy but his last hospitalization related to decompensated congestive heart failure (CHF) was in the setting of rapid Atrial fibrillation (AF) and non-STEMI and was 3 years ago. Your most recent hospitalization in February 2021 per the discharge records was for left lower lobe pneumonia which responded to antibiotic therapy and a possible infection after a toe amputation. There is no record of decompensated CHF and discharge medications listed include only Losartan 25 mg daily for management of hypertension. There are no recent records regarding your current symptoms or signs of CHF and you are also not currently reported as on full guideline directed medical therapy or complex diuretic regimens. Based on this, you do not meet published or FDA indications for Cardiomems device implantation at this time and would not meet the medical necessity requirements of the applicable CMS Section 1862(a) 1(A) rule. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an impression and custom preparation of oral surgical splint (21085) and lower jaw bone graft (21215).
You asked the Plan to pre-approve the impression and custom preparation of oral surgical splint and lower jaw bone graft. The Plan denied your request. The Plan says these services are dental in nature, and have been requested in order to prepare the jaw for dental implants. The Plan also says that here are no records from the enrollee's medical providers indicating that the enrollee has a medical condition requiring oral surgery such as bone grafting or stabilization in order to treat their condition.
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. The Plan covers the impression and custom preparation of oral surgical splint and lower jaw bone graft when the services are medically necessary and reasonable. 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 impression and custom preparation of oral surgical splint and lower jaw bone graft. Our reviewer says that these services are not medically necessary. Our physician reviewer found the Plan does not cover services that are for the care, treatment, filling, removal or replacement of the teeth or the supporting structures of the teeth. Our reviewer also found that the bone grafts appear to be for the placement of implants, which are dental in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the impression and custom preparation of oral surgical splint and lower jaw bone graft have not been met. Therefore, we decided that the Plan does not have to pre-approve an impression and custom preparation of oral surgical splint (21085) and lower jaw bone graft (21215).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Aranesp. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has a past medical history of chronic kidney disease and anemia. Based on the
medical records provided, there is no documentation that the Aranesp is medically reasonable and necessary for
the enrollee as records do not document a ferritin level of at least 100 ng/mL. Therefore, the enrollee does not
meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the documentation does not support that the enrollee meets step therapy criteria for the requested drug. Our physician reviewer found the enrollee pain related to osteoarthritis of both knees and the diagnosis confirmed with imaging studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support an indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine hysterectomy to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve a routine hysterectomy. You say that this service is medically necessary.
The Plan denied your request. The Plan says they have multiple in-network providers available to treat the
enrollee's condition.
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 routine hysterectomy to be provided by an out of network (OON) provider.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure, sepsis, COVID-19 pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered
on September 16, 2020 to January 7, 2021.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the copayments were applied 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 $150
copayment per visit to an outpatient hospital facility.
Review of the file shows that you received infusion services at an outpatient hospital facility for three dates of
service from September 16, 2020 to January 7, 2021. You have been asked to pay a $150 copayment per visit
for these services, for a total of $450. These services fall within the to 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 copayments for the outpatient hospital services rendered on
September 16, 2020 to January 7, 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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 based on the documentation provided, it is my opinion that the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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: 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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.