Persius/hicric huggingface dataset:
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 would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for DKA,
respiratory failure and an ileus. The enrollee was transiently intubated/ventilated, but is no longer
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in
transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care needs.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee qualifies for coverage due to a positive COVID-19 status. You also say that the enrollee requires a licensed nurse to assess lung sounds and assessment skills to determine a decline in their condition. The Plan denied your request. The Plan says the records show that the enrollee is functionally at their usual baseline with a dry cough, not needing oxygen, respiratory therapy, bronchodilators, and is only being watched for changes every shift, which have been stable.
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 the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. 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 a SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the services from February 4, 2019 through June 27, 2019 provided by a foreign hospital. You asked the Plan to reimburse for the services. You say that you do not agree with the amount that you have been reimbursed for these services. 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). The claim processed correctly according to the U.S. conversions of the receipts and paid on October 28, 2019.  According to your EOC on page 65, it states, "You are covered for emergency care world-wide. If you have an emergency outside of the U.S. and its territories, you will be responsible to pay for the services rendered upfront. You must submit to the Plan for reimbursement. For more information, please see Chapter 7. We may not reimburse you for all out of pocket expenses. This is because our contracted rates may be lower than provider rates outside of the U.S. and its territories. You are responsible for any costs exceeding our contracted rates as well as any applicable member cost-share." 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 reimburse for the services from February 4, 2019 through June 27, 2019 provided by a foreign hospital.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 15, 2019.
You asked the Plan to pay for the 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 require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional sacroiliac joint injection services (CPT 27096).
You asked the Plan to pre-approve the 2 additional sacroiliac joint injection services. You say that the enrollee had positive results from past injection services. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
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 2 additional sacroiliac joint injection services. Our reviewer says that the 2 additional sacroiliac joint injection services are not considered medically reasonable and necessary in this case. Our physician reviewer found examination has identified the source of the enrollee's low back pain as the sacroiliac joint. An MRI of the lumbosacral spine showed severe neural foraminal narrowing on the left side and moderate on the right side at the L5-S1 level; moderate neural foraminal narrowing on the left side and mild on the right side at the L4-L5 level. A diagnostic left sacroiliac injection on October 1, 2019 resulted in significant pain relief. The enrollee has failed conservative treatment. The Plan has approved one therapeutic sacroiliac joint injection for pain relief. The records provided do not support the medical necessity of 2 additional sacroiliac injections. 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 2 additional sacroiliac joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional sacroiliac joint injection services (CPT 27096).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Eylea injections. You asked the Plan to pre-approve Eylea. You say that the Eylea is medically necessary. The Plan denied your request. The Plan says that a trial of bevacizumab is necessary before Eylea can be considered. 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 Eylea. Our reviewer says that the Eylea is medically necessary. Our physician reviewer found the enrollee has already been receiving Eylea injections with an excellent response. Records show nearly complete resolution of the enrollee's macular edema. Step Therapy rules only apply to new prescriptions and do not apply to drugs an enrollee has already been receiving. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have been met. Therefore, we decided that the Plan has to pre-approve Eylea injections. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral appliance provided on October 29, 2019.
You asked the Plan to reimburse you for the dental item. You say that you needed the oral appliance to prevent your teeth from breaking at night. The Plan denied your request. The Plan says the oral appliance 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 oral appliance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the oral appliance provided on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient hospital stay provided from August 13, 2019 to August 17, 2019.
You asked the Plan to pay for an inpatient hospital stay. You say that the inpatient level of care was medically necessary. The Plan denied your request. The Plan says after reassessing the entire clinical situation, the result is that the initial denial is upheld and the inpatient hospitalization from August 13, 2019 to August 17, 2019, was not authorized. The patient was admitted to the hospital from the emergency room for stabilization care without the required authorization from the physician medical group. No authorization from the physician medical group was recorded. No reply from the hospital was documented.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 an inpatient hospital stay. Our reviewer says that the service was medically necessary. The review indicates that the enrollee presented to the emergency department (ED) on August 13, 2019 with the chief complaint of symptomatic bradycardia. On initial evaluation her blood pressure was in the 70's and her heart rate dropped to the 30's. She was treated with intravenous (IV) medications and fluids and her heart rate increased to the 50's. She was admitted with sick sinus syndrome and received inpatient hospital services including a dual chamber pacemaker placement. The enrollee required inpatient level of care services including the insertion of a pacemaker. The treating physician did document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital stay have been met. Therefore, we decided that the Plan has to pay for an inpatient hospital stay provided from August 13, 2019 to August 17, 2019.
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: SNF
Decision: Partially Favorable

We decided that the Plan has to pay for the skilled nursing services provided on August 17, 2019. We decided that the Plan does not have to pay for the skilled nursing services provided from August 18, 2019 to September 16, 2019.
You asked the Plan to pay for the skilled nursing services provided on August 17, 2019. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan says that the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. The Plan also says that appropriate care could have been rendered/obtained at a lower level of care, or in the home.
We decided that the Plan has to pay for the skilled nursing services provided on August 17, 2019.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before August 16, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services provided on August 17, 2019 have been met. Therefore, we decided that the Plan has to pay for the skilled nursing services provided on August 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for retreatment of previous root canal therapy (D3348) provided January 29, 2020.
You asked the Plan to waive the copayment for the dental services. You say that you are disabled, live in HUD housing and have a limited income. You received incorrect information from a plan representative and their error has created a financial hardship for you. The Plan denied your request. The Plan says this claim was 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 70% for endodontic services. You have been asked to pay $1197 for the dental services. The services fall within the Dental service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for retreatment of previous root canal therapy (D3348) provided January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 9203 provided on November 11, 2019.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99203 is not supported in the medical record. Specifically, this code is a new patient evaluation and management code. A previous evaluation and management service has been submitted by this facility. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 9203 provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve retainer crowns (D6740) for teeth # 6, 7, 11, and 12, pontics (D6240) for teeth # 8, 9, and 10, and core build up (D2950) for teeth # 6, 7, 11, and 12.
You asked the Plan to pre-approve the dental services. You say that the work that needs to be done is for the front of your mouth. You say that getting a plate is not a good option because of the other dental work that you received. You also say that the work is not cosmetic in nature, but for chewing. The Plan denied your request. The Plan says that the fixed bridge and core build up that were requested are not medically necessary.
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 dental services 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 dental services. Our reviewer says that the requested dental services are medically necessary. Our physician reviewer found the removal of the existing bridge due to recurrent caries and extraction of tooth #10 would require the placement of a new bridge since the existing retainer crowns will be removed. The reviewer found that in order to insure the proper support and retention, the new abutment retainers for teeth # 6, 7, 11 and 12 may require core buildup. The reviewer found that the use of double abutments for teeth # 6, 7 and 11, 12 to replace teeth # 8, 9 and 10, meet the criteria for coverage. Therefore, the reviewer found that the criteria for coverage of core buildup for teeth # 6, 7, 11 and 12 and a new bridge to replace teeth # 8, 9 and 10 using teeth # 6, 7, 11 and 12 as abutment retainers has been met. 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 dental services have been met. Therefore, we decided that the Plan has to pre-approve retainer crowns (D6740) for teeth # 6, 7, 11, and 12, pontics (D6240) for teeth # 8, 9, and 10, and core build up (D2950) for teeth # 6, 7, 11, and 12.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DUROLANE (J7318).
You asked the Plan to pre-approve DUROLANE. You say that this should be covered under Medicare rules. The Plan denied your request. The Plan says the enrollee has not met step therapy requirements.
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 DUROLANE. Our reviewer says that the criteria for coverage of DUROLANE have not been met. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug. The provided medical records do not indicate that the enrollee has tried Orthovisc and Monovisc or that these drugs would likely be less effective or 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 DUROLANE have
Appeal type: DME/ Orthotics
Decision: Favorable

Explanation of decision
We decided that the Plan has to pay for the Vent provided on November 22, 2019.
You asked the Plan to pay for the home ventilator (E0466). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the physician order was altered.
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home ventilator (E0466) have been met. Therefore, we decided that the Plan has to pay for the Vent provided on November 22, 2019.