Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee has multiple acute medical concerns which require frequent evaluation and nursing care. You say that, in addition, the enrollee's chronic medical issues and profound debility in the setting of morbid obesity means thatshe requires substantial bedside nursing care, which is unlikely to be available to the appropriate degree in a skilled nursing facility.The Plan denied your request. The Plan says the enrollee is receiving safe and effective care in the acute inpatient hospital.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 (ACH) for a thigh wound. The enrollee has completed a course of antibiotics and continues to receive wound care. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that 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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arm and leg pedal exerciser.
You asked the Plan to pre-approve these services. You say that the enrollee has right-sided hemiplegia from a previous stroke and the equipment would allow him to exercise at home. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an arm and leg pedal exerciser.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on August 26, 2019.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that the copay 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 $225 copayment for each separate Medicare-covered ambulance service. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance 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 forthe ambulance transport provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AmnioBand allograft.
You asked the Plan to pre-approve AmnioBand allograft. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve AmnioBand allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are suffering from a diabetic ulceration to the plantar aspect of the left foot. The enclosed progress notes advised that you are making progress from March 5, 2020 through April 15, 2020. The ulceration is noted to be getting smaller. In general, skin substitute grafting and allograft are utilized for ulcerations that have stalled from healing. The progress notes advised that your ulceration to the left foot is resolving/getting smaller with routine debridement. There is no documentation that you are offloading pressure from the foot or utilizing special shoes and/or inserts. There is no discussion on possibility of wound infection, etc. You do not have a diagnosis, condition, or symptoms that meet the Medicare criteria for coverage of the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AmnioBand allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve AmnioBand allograft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested service can be provided at an in-network facility.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral an out-of-network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick.
You asked the Plan to pre-approve Enbrel SureClick (J1438). You say that you want the enrollee treated with Enbrel Sureclick. The Plan denied your request. The Plan says the enrollee does not have a Prescription Drug Plan with this Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Enbrel injection is listed as a Self-Administered Drug Exclusion List (A53127). Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the root canal therapy (D3320) and a crown (D2750) for tooth #
12.
You asked the Plan to pre-approve the dental services. You say that there is not subcrestal decay present. You
also say that the fracture is only lingual, at the gingival level. The Plan denied your request. The Plan says that
the provided documentation reveals subcrestal decay. The Plan also says this finding results in a poor long term
prognosis for this tooth.
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 provided
documentation shows a significant portion of tooth # 12 compromised due to caries and fracture. The reviewer
also found that tooth # 12 has adequate bone support. Therefore, the criteria for coverage for a root canal and
crown have 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 the root canal therapy (D3320) and a crown (D2750) for tooth # 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the submitted documentation does not demonstrate the need for replacement of the existing crown.
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 crown 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the provided radiograph does not show any signs of marginal decay, and there are no clinical notes to indicate there is any area of decay present around the margins of this tooth. Our reviewer found that crowns are usually considered where there is significant breakdown of the tooth structure. Our physician reviewer found that there is no marginal decay seen on the provided x-ray, and no clinical notes to indicate the same. Our reviewer also found that without a clear or stated defect of the integrity of the existing crown there can be no medical necessity found for a replacement crown. 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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires daily physician consults, daily lab management, and rehab services.The Plan denied your request. The Plan says the enrollee does not need further complex hospital or nursing care.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for coronary artery disease. 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 ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolims ointment for the enrollee. You asked the Plan to pre-approve Tacrolims ointment. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs. 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-approve Tacrolims ointment for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto 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 records show that you only able to walk a short distance, and not able to participatein at least three hours of therapy a day.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 there are no medical records included to show evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from further PT and OT, but you do not require an intensive therapy program.Welooked 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 2, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that the ambulance transport was unnecessary. You say that the cost is not justified.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 $200 for each one-way Medicare-covered ambulance transport in and out-of-the service area.You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 the ambulance transport provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for a colonoscopy procedure.
You asked the Plan to pre-approve the anesthesia. 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 anesthesia. Our reviewer says that the requested anesthesia services are not considered medically reasonable and necessary in this case. Our physician reviewer found that accepted medically-necessary criteria for MAC sedation are not supported by available records. Endoscopic procedures are not anticipated to be prolonged and there is no history of or likely intolerance to standard sedatives. The enrollee is not at undue increased risk for complications due to documented comorbidity, does not have a history of active drug or alcohol abuse, or morbid obesity (BMI is 21). The enrollee is not at extremes of age and has no known history of delirium/organic brain syndromes that preclude cooperation under conscious sedatives. 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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for a colonoscopy procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided on December 24, 2019.You asked the Plan to waive the copayment forphysical therapy. You say that there was no mention of costs or copayments. You say that you were under the impression that insurance covered it.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 $40 copayment for each in-network, Medicare-covered therapy visit.You have been asked to pay a $40 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation services" 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 forphysical therapy provided on December 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXolair injections.You asked the Plan to pre-approvethe Xolair injections. You say that Xolairis medically necessary.The Plan denied your request. The Plan says the enrollee's Plan does not cover outpatient prescription drugs.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 pre-approveXolair injections.Benefits for the Xolair injectionsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit on November 13, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you were forced to go the emergency room. You say the emergency room ran tests and you were fine to go home. The Plan denied your request. The Plan says you have been charged the correct cost sharingamount.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 $110 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during your emergency room visit.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 emergency room visit provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to a partial denture (D5650 x 2) provided on September 16, 2019.You asked the Plan to pay for the dental services. You say that adding a tooth to a partial denture is covered under most dental claim policies. You say that you pay more for your dental coverage, but have less coverage. You also say that this was not disclosed at the time you purchased the policy, nor were you offered a policy that provided coverage for a partial denture.The Plan denied your request. The Plan says adding a tooth to a partial denture is not listed as 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 addition of a tooth to a partial denture is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the addition of a tooth to a partial denture (D5650 x 2) provided on September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of payment. 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 January 1, 2018. 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.