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

We decided that the Plan does not have to pay for inpatient physician services provided to the enrollee on June 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until September 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for inpatient physician services provided to the enrollee on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mental health services provided on June 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe mental health services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization wasnot obtained to seek out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe mental health services provided on June 23, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on October 6, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were having another medical emergency. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $325 copayment for ambulance services. You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall 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 ambulance services provided by a participating provider on October 6, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea transthoracic echocardiography (93306).You asked the Plan to pre-approvea transthoracic echocardiography (93306). You say that the requested transthoracic echocardiography (93306) is medically necessary.The Plan denied your request. The Plan says that the requested transthoracic echocardiography (93306) is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a transthoracic echocardiography (93306). Our reviewer says that the requested transthoracic echocardiography (93306) is medically necessary. Our physician reviewer found the enrollee has had 3 vessel CABG revascularization surgery complicated by stroke. He is now recovering. Changes in LVEF can occur after CABG surgery and evaluation of baseline LV function after major cardiac surgery is reasonable and medically necessary to establish baseline function for longterm management and consideration of medical therapy including ACE inhibitors and beta blockers--especially if the LVEF is depressed. A single transthoracic echocardiogram after recovery from CABG is therefore reasonable and medically necessary based on the CMS rules and could lead to changes in long-term medical management.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 transthoracic echocardiography (93306) have been met.Therefore, we decided that the Plan has to pre-approvea transthoracic echocardiography (93306).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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure and COVID pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom orthotics (inserts).
You asked the Plan to pre-approve foot orthotics. You say that you need assistance are you are no longer working due to COVID-19. The Plan denied your request. The Plan says the medical records did not show that this will be used for proper functioning of a leg brace.
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 custom orthotics (inserts).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria 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 thecomplexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for constrictive pericarditis and had a pericardectomy. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The records do not document a need for an intensive rehabilitation program.There is also not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7953) for the enrollee.
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.
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 pre-approve dental services (D7953) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a history of hypertension and dementia, who was admitted to the hospital on 2/1/21 with altered mental status. The enrollee was diagnosed with a urinary tract infection, and asymptomatic COVID-19. The enrollee has ambulated 40 feet with a rolling walker. The enrollee tolerates 30 minutes of exercise with multiple rests. The enrollee follows one-step commands. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation supports that the enrollee would likely benefit from multiple therapies, but not at least 3 hours a day/5 days a week. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Botox injections (J0585).
You asked the Plan to pre-approve the Botox injections. You say that you would like reconsideration because the member needs Botox to dilate small vessels and optimize the blood flow to their fingers. The Plan denied your request. The Plan says the clinical value and effectiveness of Botox injections in the setting of ischemic fingers due to hypercoagulopathy have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the Botox injections. Our reviewer says that the requested use of Botox is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found the use of Botox is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Botox injections (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea breast prosthesis and mastectomy bra (L8000, L8030) from an out-of-network provider.You asked the Plan to pre-approvethe breast prosthesis and mastectomy bra. You say that the items are medically necessary.The Plan denied your request. The Plan says while these items are medically necessary, they must be obtained from a network provider. There are network providers available.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items.Therefore, we decided that the Plan does not have to pre-approvea breast prosthesis and mastectomy bra (L8000, L8030) from an out-of-network provider.
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 requested continuation of LTACH services are medically necessary.The Plan denied your request. The Plan says the requested continuation of LTACH services are 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 continuation of LTACH services are not medically necessary. Our physician reviewer found the enrollee was admitted to the current acute care hospital with abdominal pain, nausea, and vomiting related to ischemic bowel with infection. He was found to be in atrial fibrillation, treated with cardizem drip. He was treated with exploratory laparotomy and multiple wound washout as well as wound VAC and TPN. He developed a fistula which was managed. He required intubation and later tracheostomy. He later was decannulated and is on trach collar. Wound has been improving and requires basic open wound care at this time. The plan includes 2 moreweeks of antibiotics.The enrollee is stable and improving gradually according to the notes and only requires short term additional acute care services which can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening of a patient (D0190), assessment of a patient (D0191), diagnostic casts (D0470), guided tissue regenerations (D4266), endosteal implants (D6010), connecting bars (D6055), prefabricated abutments (D6056), bone grafts at time of implant placement (D6104), x-rays/surgical implant indexes (D6190), adjunctive procedure (D9999), and pay more for extractions (D7140) provided from March 23, 2020, to June 10, 2020.
You asked the Plan to pay for the dental services. You say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that these services were rendered by an out-of-network provider, and the extractions were paid accordingly.
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, these services are not among those covered under this benefit. The contract also states that you are responsible for the difference between the billed amount and allowed amount for the extractions. Therefore, we decided that the Plan does not have to pay
for the screening of a patient (D0190), assessment of a patient (D0191), diagnostic casts (D0470), guided tissue regenerations (D4266), endosteal implants (D6010), connecting bars (D6055), prefabricated abutments (D6056), bone grafts at time of implant placement (D6104), x-rays/surgical implant indexes (D6190), adjunctive procedure (D9999), and pay more for extractions (D7140) provided from March 23, 2020, to June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the drug is approved under the enrollee's Part D benefit. 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. 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-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray and preventive procedure provided on September 21, 2020.
You asked the Plan to pay for the additional intraoral periapical x-ray and preventive procedure. You say that you would like these services to be covered. The Plan denied your request. The Plan says benefits for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded. The Plan also says that the preventive procedure is not covered.
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 unspecified preventive procedure is not among those covered under this benefit. The contract also clearly states that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on September 21, 2020, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray and preventive procedure provided on September 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.
You asked the Plan to pre-approve Prednisone. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Prednisone.
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTremfya.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveTremfya.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights