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 for enrollee.You asked the Plan to pre-approve IRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 25, 2020 after a motor vehicle crash. Injuries include a sternal fracture, left distal radius fracture, left tibial plateau fracture, and multiple contusions. He is now medically and hemodynamically stable and afebrile. He does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear from the records that he would be able to fully benefit from and participate in an intensive therapy program in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor 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 for enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental service. You say that you tooth is broken down to the gum. You also say that you need to have this tooth extracted by an oral surgeon. The Plan denied your request. The Plan says dental services must be provided by a participating general dentist.
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, dental services must be received from a particiapating general dentist. The requested provider is an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnsure nutritional supplement.You asked the Plan to pre-approveEnsure nutritional supplement. You say that because of a medical condition the enrollee is struggling to eat solid foods.The Plan denied your request. The Plan says enteral nutrition products administered orally and related supplies are non-covered.The Plan must follow Medicare rules. Medicare rules say that enteral nutrition products administered orally are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral formula (B4150) have not been met. Therefore, we decided that the Plan does not have to pre-approve Ensure oral liquid nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan des not have to pre-approve back brace.You asked the Plan to pre-approvethe brace. You say that you had an accident and hurt your back badly. You would like the brace that was prescribed to see if it helps you.The Plan denied your request. The Plan says information reviewed does not show sufficient clinical information to reference a specific clinical practice guideline or policy to make a determination. Specifically, there are no diagnosis codes, procedure codes, or clinical documentationto support medical necessity.The Plan must follow Medicare rules. Medicare rules say that provider or suppliers must corroborate the information in the enrollee's medical record. We looked at the file and Medicare rules. There wasno information indicating the type of broace or reason for necessity for your back injury. There are no diagnostic codes or procedure codes to support medical necessity. Based on this information, we decided that Medicare rules for coverage of the brace have not been met.Therefore, we decided that the Plan does not have to pre-approve back brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the external defibrillator provided on October 9, 2019.You asked the Plan to waive the coinsurance for the external defibrillator. You say that you are being charged an extra month since you mailed it back two days after the month expired. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment from an in-network durable medical equipment provider. You have been asked to pay $579.90 which is 20% of the allowed amount for the external defibrillator. The allowed amount is $2,899.50. ($2,899.50 x 20% = $579.90). The external defibrillator falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the external defibrillator provided on October 9, 2019.
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 enrollee is not in danger of regaining maximum
function. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval
of IRF 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 the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forframes (V2020) purchased August 15, 2019.You asked the Plan to payforthe frames. You say that you were informed that this provider was not in-network, however you went on ahead with the purchase. But before you left the mall the frames fell and broke and you had no choice but to purchase another.The Plandenied your request. The Plan says enrollee's must receive their vision services from an in-network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services the services are provided by a participating network provider.We looked at the file and the Plan's rules. Services are covered when provided by anin-network provider. Based on this information, we decided that the Plan's rules for coverage of the frames have not been met.Therefore, we decided that the Plan does not have to pay forframes (V2020) purchased August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on October 20, 2019.
You asked the Plan to reimburse you for the dental service. The Plan denied your request. The Plan says periodontal maintenance 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, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on October 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the special eye exam (92225) provided August 17, 2019You asked the Plan to pay for the vision services. You say that you are not being reimbursed correctly for the vision services that you paid for.The Plan denied your request. The Plan says procedure code 92225 has not met the associated diagnosis code relationship criteria.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 92225 is an extended ophthalmosocpy.We find that CPT code 92225is not supported in the medical record.Specifically, there is lack of a required diagnosis that was documented by the physician for this procedure. Based on this information, we decided that Medicare rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for the special eye exam (92225) provided August 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that orthotics are necessary to avoid surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) 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-approvethe LTACH services. You say that the clinical records provided support the need for LTACH care.The Plan denied your request. The Plan says LTACH care is not medically necessary. The Plan says that they will continue to cover acute level of care at the current 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), having been admitted with altered mental status and electrolyte abnormalities. The enrollee was intubated/ventilated. She subsequently received a tracheotomy and feeding tube. The enrollee has been weaned from the ventilator to a tracheotomy collar. Her long-term prognosisappears to be poor. 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 carefor 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on August 29, 2019You asked the Plan to waive the copayment for the podiatry visit. You say that you were billed in error because the provided did not perform the lesion cutting service. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for podiatry services. You have been asked to pay a $20 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The medical record shows the lesion cutting service was performed.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 podiatry visit provided on August 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial upper denture with metal frame (D5213).You asked the Plan to pre-approve the dental service. You say that you did impressions for dentures in 2017. You say that the partial did not fit right. You say that they were sent back twice to do not fitting. You also say that you ended up never receiving them.The Plan denied your request. The Plan says partial dentures are covered once every 5 years. The Plan also says the frequency limit for a partial denture has been reached.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and partial dentures are a covered service, the frequency limit has been reached. The record shows the Plan paid for an upper denture that you received on November 10, 2017.Therefore, we decided that the Plan does not have to pre-approve the partial upper denture with metal frame (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bi-level positive airway pressure device.You asked the Plan to pre-approve a BiPAP. You say that the enrollee needs a BiPAP.The Plan denied your request. The Plan says there is no documentation of failure of CPAP therapy.The Plan must follow Medicare rules. The rules say that for any item to be covered by Medicare it must be reasonable and necessary.We looked at the file and Medicare rules. The record shows the enrollee was non-compliant with the CPAP. Based on this information, we decided that Medicare rules for coverage of a BiPAP have not been met.Therefore, we decided that the Plan does not have to pre-approve a bi-level positive airway pressure device
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveImfinzi.You asked the Plan to pre-approveImfinzi. You say that the requested Imfinzi is medically necessary.The Plan denied your request. The Plan says the requested Imfinzi is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Imfinzi. Our reviewer says that the requested Imfinzi is not medically necessary. Our physician reviewer found the enrollee is diagnosed with malignant neoplasm of upper lobe, left bronchus or lung (Non-small cell Lung Cancer Thorax-Clinical Stage IIB). Pancoast tumor, status post chemoradiation, then resection, then durvalumab.The requested use of Imfinzi is not FDA-approved for the enrollee's diagnosis at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met.Therefore, we decided that the Plan does not have to pre-approve Imfinzi.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on March 2, 2019.
You asked the Plan to waive the copayment for an MRI. You say that this was a preventative mammogram and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for advanced radiology services. The medical records show that you received an MRI on March 2, 2019. Therefore, you are responsible to pay the allowed amount of $247.46, which is less than the $250 copayment. You have been asked to pay $247.46 for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an MRI provided on March 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for tooth #'s 20 and 27.
You asked the Plan to pre-approve the crowns. You say that the two crowns on the front were already broken. You also say that you need this service as soon as possible because you do not want false teeth. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, crowns, bridges, inlay/onlay and periodontal work may not be provided more often than once per tooth every five (5) years. The record shows that you received a crown on tooth #27 on May 1, 2016, and crown on tooth #20 on August 1, 2017, and your crowns benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve crowns for tooth #'s 20 and 27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Halo Safety Ring Bed Rail.You asked the Plan to pre-approvea Halo Safety Ring Bed Rail. You say that regular bed rails are not permitted at the assisted living facility.The Plan denied your request. The Plan says a Halo Safety Ring Bed Rail is not covered by Medicare.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. AHalo Safety Ring Bed Railisconsidered a convenience item.Medicare does not cover the cost of detachable bed rails that are meant to be used on conventional beds.Therefore, we decided that the Plan does not have to pre-approvea Halo Safety Ring Bed Rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3 alveoloplasties in conjunction with extractions and 7 extractions.You asked the Plan to pre-approve the alveoloplasties and extractions. You say that due to severe caries you require extractions of all of your remaining teeth.The Plan denied your request. The Plan says alveoloplasty is not a covered benefit under your plan. The Plan also says that the extractions exceed your benefit limitation.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 benefitin excess of Medicare coverage, alveoloplasty is not among those covered under this benefit. The contract also clearly states that you are limited to 3 extractions per calendar year. The record also shows that the Plan approved three extractions with thisprovider on January 9, 2020, and your extractions benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve3 alveoloplasties in conjunction with extractions and 7 extractions.