Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent transportation.
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 and it is a specific exclusion.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance.
The Plan follows the same rule.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pre-approve non-emergent transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays used for services provided on December
31, 2019 billed with code A4550.
You asked the Plan to pay for the surgical trays. You say that the provider has active credentials and should be
paid for the services rendered. The Plan denied your request. The Plan says the provider's license was not
active during this time and he cannot be paid for these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code A4550 has a status indicator of "B" in the Physician Fee Schedule meaning that payment is always
bundled into other services provided. Based on this information, we decided that Medicare rules for coverage
of the surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for the
surgical trays used for services provided on December 31, 2019 billed with code A4550.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of lower or sacral facet joint nerves for the enrollee.You asked the Plan to pre-approvethe procedure. You say that this is medically necessary.The Plan denied your request. The Plan says it is unclear if there is any physical therapy or home exercises that are being utilized as part of a comprehensive program.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not received greater than 50% pain relief, for at least six months after the RFA interventions. Therefore, this does not meet criteria and the request is deemed not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of the procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvedestruction of lower or sacral facet joint nerves for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 25, 2019 through July 30, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on July 25, 2019 and discharged on July 30, 2019. You were asked to pay a $395 copayment per day from July 25, 2019 through July 28, 2019, days 1-4 of your inpatient stay. There were no copayment charges from July 29, 2019, day 5 of your inpatient hospital care until your day of discharge July 30, 2019. Per your contract there is a $395 copayment per day required for days 1-4 for in-network inpatient hospital care. 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 inpatient hospital care from July 25, 2019 through July 30, 2019 provided by an in-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the type of treatment requested is not supported to treat this cancer type.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found arguably SBRT is more cost-effective (which would benefit the insurer), and perhaps equivalent or superior to conventionally fractionated IMRT/IGRT, though for high-risk disease, is still considered controversial. As such, based upon NCCN guidelines, corroborated by expert opinion, SBRT for high risks prostate cancer, in the absence of ADT, would not be "furnished in accordance with accepted standards of medical practice". 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sodium Hyaluronate for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested viscosupplement agent is subject to step therapy.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found step therapy, as outlined by the plan, requires Orthovisc and Monovisc be trialed first. The reviewed records do not include any medical records. Without the documentation, it is unknown if guidelines are met. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Sodium Hyaluronate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Space Oar Hydrogel procedure.
You asked the Plan to pre-approve a Space Oar Hydrogel procedure. You say that the requested Space Oar
Hydrogel procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not
meet criteria for the requested Space Oar Hydrogel procedure.
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 a Space Oar Hydrogel procedure. Our
reviewer says that the enrollee does not meet criteria for the requested Space Oar Hydrogel procedure. Our
physician reviewer found the enrollee is with stage T1c Gleason's grade 4+4 adenocarcinoma of the prostate
with baseline PSA of 12.96 ng/mL. MRI indicated prostate size of 131 cc. Downsizing with Lupron/Eligard
was initiated. Preferred treatment by the enrollee was external beam radiation. Request is for coverage of Space
Oar Hydrogel procedure.
The enrollee does not have a covered indication for the requested Space Oar Hydrogel procedure. Specifically,
the above coverage criteria have not been met. There is no documentation that the prostate size is less than 80
cc. Also, the enrollee does not have low* or favorable Intermediate Prostate Cancer Risk Group (1 -5) (AUA or
NCCN) criteria.
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 Space Oar Hydrogel procedure have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Space Oar Hydrogel procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records, there are no identifiable skilled nursing service needs.There are no identifiable skilled therapy service needs.The records do not show you require skilled nursing or therapy services daily.Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.Medicare coverage criteria are not met. 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays you received on January 22, 2020.
You asked the Plan to pay for the periapical x-rays. The Plan denied your request. The Plan says this is not a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The plan covers only those dental services listed in the Evidence of Coverage. Periapical x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the periapical x-rays you received on January 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health occupational therapy (OT) visits (G0299,
G0156, G0151).
You asked the Plan to pre-approve 7 home health OT visits. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
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 7 home health OT visits. Our reviewer
says that the services are not medically necessary. Our physician reviewer found the documentation does not
reveal that you need occupational therapy beyond what was already approved and there are no specific
occupational therapy treatment goals noted. The documentation does not support unique skills of a professional
therapist are needed to safely and effectively provide treatment. Services do not only need to be safely and
effectively performed by a therapist, or under the supervision of a therapist. The requested services are not part
of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow
further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 7 home health OT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 7 home health occupational therapy (OT) visits (G0299, G0156, G0151).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on January 9, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the enrollee was not transport by your request. The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for each one-way Medicare covered ground ambulance trip. The enrollee has been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare covered ground ambulance trip benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on January 9, 2020.
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 records provided support the need for IRF care.
You say that the enrollee barely has any movement and does not have anyone to care for her and give her the
help she needs. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
The Plan says that the enrollee's care could be provided in another setting.
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 the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate
that this therapy must be in an IRF with an intensive level 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical-first x-ray (D0220) and limited oral exam (D0140) provided January 17, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the claim. You chose both dentists from the plan's directory of dentists. The Plan denied your request. The Plan says this service is not a covered 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. 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 for intraoral-periapical-first x-ray (D0220) and limited oral exam (D0140) provided January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removals of torus mandibularis (D7473 x2) and
complete maxillary denture (D5110) provided on December 30, 2019.
You asked the Plan to pay for the removals of torus mandibularis and complete maxillary denture. You say that
your dentist said these procedures should be covered under your Medical policy. You also say that you are on a
fixed income. The Plan denied your request. The Plan says removal of torus mandibularis is not a covered
benefit. The Plan also says that the maximum allowed for replacement of existing full or partial maxillary
dentures has been met.
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, removal of torus mandibularis is not
among those covered under this benefit. The contract also clearly states that complete denture, immediate
denture, or partial denture are limited to one set of dentures every five years. The record shows that you
received an immediate maxillary denture on May 7, 2019 and your dentures benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the two removals of torus mandibularis (D7473
x2) and complete maxillary denture (D5110) provided on December 30, 2019.
Your complaint about being disappointed 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the allergy shot rendered on January 2, 2020.You asked the Plan to waive the copayment for these services. You say that the provider told you there would not be a copayment.The Plan denied your request. The Plan says the copayment 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 $20 copayment per visit to a specialist. Review of the file shows that you received an allergy shot during a specialist visit on January 2, 2020. Per your contract with the Plan, there is a $20 copayment per visit to a specialist. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $10.36. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $10.36 for these services.Therefore, we decided that the Plan does not have to waive the copayment for the allergy shot rendered on January 2, 2020.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not 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 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. Your current medical status does not require intensive physician or nursing oversight in an IRF. Medicare coverage criteria are not met. 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: 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 you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 based on the medical records provided, the current acute care hospital is able to provide all of the services the enrollee requires. Continued care at this level is appropriate until the enrollee is stable for transfer to a lower level of care such as an inpatient rehabilitation facility, skilled nursing facility, sub-acute rehabilitation facility, or home health 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.