Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation
provided, the enrollee is not shown to have required the intensity of services provided at an IRF, at the time of
admission. Specifically, the enrollee is not shown to have required fifteen hours per week of rehabilitative
services with regular physician evaluation. The enrollee's care needs could have been met 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 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 waive the coinsurance foran out-of-network immunization (90662, G0008) provided on September 28, 2020.You asked the Plan to waive the coinsurance foran out-of-network immunization. You say that you believed this provider was in-network and this would be fully covered.The Plan denied your request. The Plan says this provider is not in-network and these services processed 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% coinsurance for out-of-network Medicare-covered immunizations. You have been asked to pay a 30% coinsurance for an out-of-network immunization. The Plan has confirmed that the provider of this service is out-of-network. 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 foran out-of-network immunization (90662, G0008) provided on September 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the stress echocardiogram with doppler.
You asked the Plan to pre-approve the stress echocardiogram with doppler. You say that you would like
reconsideration because the member has not had specific symptoms and you are suspicious for myocardial
ischemia. The Plan denied your request. The Plan says stress echocardiogram is not reasonable or necessary 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 stress echocardiogram with doppler.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the records do not show that the member has any cardiac symptoms,
cardiovascular exam abnormalities and an electrocardiogram.
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 stress echocardiogram with doppler have not been met. Therefore, we
decided that the Plan does not have to pre-approve the stress echocardiogram with doppler.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August
9, 2020, through August 12, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay
the cost share. The Plan denied your request. The Plan says the cost share was 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 $295
copay per day for days one through six for inpatient hospital care.
You have been asked to pay a $295 copay per day for days one through six for inpatient hospital care. This
service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan ($295 x 3 = $885. 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 inpatient hospital care provided on August 9, 2020, through August 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for zoster (shingles) vaccine (90750) provided October 7, 2020.
You asked the Plan to pay for the shingles vaccine. You say that you were told if you went to your primary doctor's office your insurance would help you pay. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pay for zoster (shingles) vaccine (90750) provided October 7, 2020.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac (SI) joint radiofrequency ablation (RFA).You asked the Plan to pre-approvethe RFA. The Plan denied your request. The Plan says this is 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 the RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that sacroiliac joint radiofrequency ablation is considered experimental/investigational. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit. Small clinical trials evaluating radiofrequency denervation for facet joint pain, discogenic low back pain, radicular pain, and chronic sacroiliac joint pain have generally shown no effectiveness or modest, mostly short-term, benefit.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 RFA have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2020
You asked the Plan to pay for the testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says to report a CGP, service providers should use CPT code 81479.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 10, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 carefrom 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe medical services provided to the enrollee by an out-of-network provider on August 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveoneProlia injection every sixmonths.You asked the Plan to pre-approvethe Prolia. You say that you recommend the enrollee use Prolia for added fracture prevention.The Plan denied your request. The Plan says that there are few data on the effects of Denosumab on fracture healing.The Plan must follow Medicare rules. The rules saythat 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 the Prolia. Our reviewer says that oneDenosumab injection every six months is medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided there is documentation that the Denosumab injection (Prolia) every six months is medically reasonable and necessary andis safe and effective for the for the enrollee. Our reviewer found that despite the results of the bone density scan showing minimal osteopenia, the fact that the enrollee has had two recent fractures from reportedly minimal trauma (fragility fractures) confirms a clinical diagnosis of osteoporosis. Our physician reviewer also found that Prolia is approved by the Food and Drug Administration for the treatment of postmenopausal osteoporosis, high risk of fracture.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 Prolia have been met.Therefore, we decided that the Plan has to pre-approveone Prolia injection every six months.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 pay for the domiciliary or rest home visit (99334, 99335) rendered by the out of network (OON) provider from June 16, 2020, through August 4, 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 the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the domiciliary or rest home visit (99334, 99335) rendered by the out of network (OON) provider from June 16, 2020, through August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite of two surfaces and resin-based composite of three surfaces provided on August 17, 2020.You asked the Plan to pay forthe resin-based composites. You say that you thought this was a covered benefit. You also say that the provider never advised you that these services would not be covered.The Plan denied your request. The Plan says your plan does not cover this procedure.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 pay forthe resin-based composite of two surfaces and resin-based composite of three surfaces provided on August 17, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe medical services provided on July 16, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you did obtain authorization and provided service in good faith.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 forthe medical services provided on July 16, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment forthe nuclear medicine studyreceived June 30, 2020.You asked the Plan to waive the deductible and copayment forthenuclear medicine study. You say that the test received was non-essential and therefore you should not be charged for it.The Plan denied your request. The Plan says you must pay your entire deductible and any required copayment amounts for covered medical services.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 $750 deductible for covered medical services as well as a $200 copayment amount for outpatient diagnostic tests and therapeutic services and supplies. The item or service you asked the Plan to waive the deductible for falls within the benefit category of outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the nuclear medicine studywas performedon June 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible forthenuclear medicine studyreceived June 30, 2020.You have been asked to pay a $200 copaymentforanuclear medicine study. A nuclear medicine studyfalls within the outpatient diagnostic tests and therapeutic services and suppliesbenefit 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 nuclear medicine study performedJune 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing services at 7 visits per week
and continued home health aide services.
You asked the Plan to pre-approve continued skilled nursing and home health aide services. You say that the
records should support the necessity of the service in dispute. The Plan denied your request. The Plan says
although the enrollee requires skilled nursing for medication oversight/compliance and assessment, the
personal care needs can be met at a less intense level such as an agency for personal Care service.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 continued skilled nursing and home
health aide services. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the documentation does not support that
the enrollee requires more than two skilled nursing services weekly or skilled rehab services to provide
treatment that is medically necessary. The enrollee does not require rehab services to effectively provide
treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to
maintain the enrollee's condition and/or prevent deterioration. He does require medication management and
oversite due to a complex medication regimen. He is able to accomplish his own activities of daily living and 
does not require a home health aide. The enrollee has been medically stable without any recent exacerbations
of chronic medical problems or hospitalizations. He can be cared for by the services approved by the Health
Plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued skilled nursing and home health aide services have not been met.
Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing services at 7 visits
per week and continued home health aide services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 29, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 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 September 29, 2020. 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 September 29, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment foran electrocardiogram (EKG) provided on September 22, 2020.You asked the Plan to waive the copayment forEKG. You say that you had this test done on the same day and at the same facility as laboratory testing, so they should be covered with a single $10 copayment.The Plan denied your request. The Plan says that the copayment amount you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $10 copayment per day, per facility for lab services, diagnostic procedures, and diagnostic tests. The Plan says you must pay the allowed amount of $8.51 for EKG in addition to the $10 copayment you have already been asked to pay for laboratory testing. The EKG and lab testing were performed on the same day and at the same facility; therefore, only one copayment can apply to these services.Based on the Plan contract, you cannot be asked to pay more than the $10 copayment you have already been asked to pay, and no separate copayment applies to this EKG. Therefore, we decided that the Plan has to waive the copayment foran electrocardiogram (EKG) provided on September 22, 2020.