Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on July5, 2019.You asked the Plan to pay forthe knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Planmust follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe knee orthosis and suspension sleeve provided by Prescription Connection on July 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is not able to be left home alone for a long period of time. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
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 reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not need an intensive team approach for care and does not need to see a rehabilitation doctor three times per week.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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not reveal that you require the intensity of an IRF stay with close physician or nursing supervision.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.You asked the Plan to pre-approvea ventilator. The Plan denied your request. The Plan says the enrollee has not been on home oxygen, and has not tried, failed, or responded to BiPAP therapy.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our physician reviewer found that the enrollee has COPD with recent exacerbations. There are no pulmonary function tests to document severity, and no arterial blood gas data to document CO2 retention. There is no evidence that BiPAP has been tried and failed. BiPAP can provide the AVAPS-AE mode of ventilation, and Medicare does not cover home ventilators when used as BiPAP. Therefore, a home ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approvea home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approverevision/conversion hip arthroplastyYou asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaystheremust be doctor's notes that show the enrollee is healthy enough for this surgery.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support any of the coverage criteria (Instability of one or both components; Fracture or mechanical failure of the implant; Recurrent or irreducible dislocation; Infection; Treatment of a displaced periprosthetic fracture; Clinically significant leg length inequality; Progressive or substantial bone loss; Clinically significant audible noise; or Adverse local tissue reaction).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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approverevision/conversion hip arthroplasty
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 14, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 12, 2019.You asked the Plan to waive the copayment for the office visit. You say that you were charged a specialist fee. You say that you should only be charged for a PCP.The Plan denied your request. The Plan says the copayment 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 $10 copayment for each Medicare-covered primary care doctor visit with a Tier 2 primary care physician. You have been asked to pay a $10 copayment for the office visit. The officevisit falls within the "Physician/Practitioner services, including doctor's office visits" 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 forthe office visit provided on September 12, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 1, 2019 to August 31, 2019.You asked thePlan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have skilled nursing or skilled rehabilitation needs.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 1, 2019 to August 31, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the astigmatism correcting function of intraocular lens (V2787).You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-CIOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL.Therefore, we decided that the Plan does not have to pre-approve the astigmatism correcting function of intraocular lens (V2787).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite, one surface, for a posterior tooth (D2391) and a resin based composite, 2 surfaces, for a posterior tooth (D2393) provided on December 11, 2019.
You asked the Plan to pay for the dental services. You say that at least 1 filling should have been covered for your visit on December 11, 2019. The Plan denied your request. The Plan says the frequency limit for fillings has been reached. The Plan says 4 fillings per year are 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 and fillings are a covered service, the frequency limit has been reached for this service. The record shows that the Plan previously paid for 1 filling that you received on April 22, 2019 and the 3 fillings that you received on December 5, 2019, thus reaching the frequency limit. Therefore, we decided that the Plan does not have to pay for the resin based composite, one surface, for a posterior tooth (D2391) and a resin based composite, 2 surfaces, for a posterior tooth (D2393) provided on December 11, 2019.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee had been admitted for respiratory failure, requiring mechanical ventilation. Currently ongoing needs
for acute care are noted in the provided records including continued respiratory weaning. However, overall his
clinical status has been progressively improving, allowing him to use the wheelchair and participate in therapy
while kidney status and respiratory status has been more stable. Acute care is not likely to be needed beyond a
25-day period. The enrollee's required treatments/services are already being administered and covered in the
current setting. There would be no advantage to transfer to LTACH at this stage and transfer to a lower level of
care when able would be most appropriate. Therefore, this request for LTACH services will be considered not
medically necessary 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 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 waive the copayment forthe eye exam with photos provided on September 24, 2019.You asked the Plan towaive the copayment forthe eye exam with photos. You say that this was your diabetic eye exam and should be 100% covered. The Plan denied your request. The Plan says you have been charged 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 $40 copayment for each Medicare-covered eye exam to diagnose andtreat diseases and conditions of the eye. You have been asked to pay a $40 copayment for the eye exam with photos. The eye exam with photos falls within the "Vision care" benefit category. The record shows you were billed for the eye exam with photos.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 forthe eye exam with photos provided by on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on August 27, 2019.You asked the Plan to pay for the services. You say that this is medically necessary.The Plan denied your request. The Plan says this was provided outside of the network of providers.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 rendering 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 office visit services provided to the enrollee on August 27, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on July 19, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the specialist did not provide the service. You say that you should be reimbursed $25.The Plandenied your request. The Plan says the copayment 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 Planclearly says that you must pay a $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show that the office visit was at a specialist's office. 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 forthe office visit provided on July 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment of a root canal obstruction (D3331) and incomplete endodontic therapy (D3332) for tooth # 19.You asked the Plan to pre-approvethe dental services. You say that you are experiencing pain in the affected tooth. You say that the pain is affecting your ability to eat and drink.The Plan denied your request. The Plan says the services you requested are not covered services.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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvetreatment of a root canal obstruction(D3331) and incomplete endodontic therapy (D3332) for tooth # 19.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOxycodone tablets.You asked the Plan to pre-approveOxycodone tablets. You say that you would like thePlan to reconsider their denial.The Plan denied your request. The Plan says Oxycodone tablets are not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveOxycodone tablets.Benefits for Oxycodone tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2952) provided on October 21, 2019.You asked the Plan to pay forthe dental service. You say that you thought the service you received was routine in nature and it would be covered.The Plan denied your request. The Plan says the prefabricated post and core in addition to a crown is not 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 service you received is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe prefabricated post and core in addition to a crown (D2952) provided on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe needs can be safely met in a lower level of care, such as a skilled nursing facility, if ordered by the doctor.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 review has determined thatthe complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 atthis 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).