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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 based on the documentation provided, the enrollee is currently undergoing treatment as an outpatient for chronic, non-healing wounds. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires the level of services provided at a LTACH. Therefore, admission to a LTACH is not currently medically necessary or reasonable. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment a diagnostic mammogram (77065) provided
October 30, 2019.
You asked the Plan to waive the copayment the mammogram. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct cost share was 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 $100
copayment for Diagnostic Radiology.
You have been asked to pay a $86.29 copayment for the mammogram. The mammogram falls within the
Diagnostic Radiology benefit category. The allowed amount is less than the $100 specified in the contract. 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 a diagnostic mammogram (77065) provided October 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says 100 skilled days have been used.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 22, 2020 to April 30, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 11, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 11, 2019
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 the records do not show intensive rehab needs.
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 has been able to ambulate greater than household distances and is performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. The enrollee is currently limited due to atrial fibrillation with rapid ventricular response. He would not be expected to be able to safely fully participate in or benefit from the required intensity of an acute rehabilitation therapy program at this time. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. Once his cardiac condition has been stabilized, the member's care can be appropriately provided at an SNF level. He lives with his wife and home based-care may also be an option. Acute level rehabilitation is not medically necessary. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on August 9, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that there is no authorization on file for the services rendered.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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visits and the an electrocardiogram provided on October 17, 2019 and November 7, 2019.
You asked the Plan to waive the cost share for the specialist office visits and the electrocardiogram. You say that the charges were not discussed with you prior to the visits and are excessive for the services received. 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. Your contract with the Plan says that there is a $500 deductible that applies towards in-network specialist office visits and electrocardiograms, and 20% coinsurance for services obtained from an out-of-network specialist, and 20% coinsurance for in-network Medicare-covered non-radiological diagnostic services. The specialist office visits you asked the Plan to waive the cost share for fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The electrocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards in-network specialist office visits and electrocardiograms, 20% coinsurance for in-network specialist office visits, and 20% coinsurance for electrocardiograms. See chart below.

This cost sharing is a contractual obligation that had not been met at the time the specialist office visits and the electrocardiogram were received on October 17, 2019 to November 7, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visits and an electrocardiogram provided on October 17, 2019 and November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services as in-network.You asked the Plan to pre-approve the physician's services as in-network. The Plan denied your request. The Plan says services provided by a non-contract provider are only approved as in-network when the service is not available through the Plan's provider network. If the enrollee wishes to pursue treatment with the requested physician, he may do so using his out-of-network POS benefits.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 Plan contract also says the enrollee may receive care from an out-of-network provider for most covered services using the Plan's POS option.Prior authorization rules may still apply for services received using the POS option. The enrollee's costs may be higher using out-of-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services as in-network. Therefore, we decided that the Plan does not have to pre-approve the physician's services as in-network.
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 requested admission to an IRF does not meet criteria.
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 member is status-post stroke having received TPA. The member's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She is ambulating greater than household distances and is performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. The member is limited by decreased endurance and shortness of breath with higher-level activity. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transmitter, external for use with interstitial continuous glucose monitoring (A9277) for the enrollee. You asked the Plan to pre-approve a transmitter. You say that the enrollee requires this because of his hearing impairments. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and code A9277 is used to describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve a transmitter, external for use with interstitial continuous glucose monitoring (A9277) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns and a resin-based composite.
You asked the Plan to pre-approve the crowns and resin-based composite. The Plan denied your request. The
Plan says these services are not covered under your benefit plan.
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. The record also shows that you are not enrolled in the optional benefit
that covers comprehensive dental services. Therefore, we decided that the Plan does not have to pre-approve
two crowns and a resin-based composite.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you cannot get around without a power wheelchair. The Plan denied your request. The Plan says your current power wheelchair is less than 5 years old.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. You received a power wheelchair on December 16, 2015, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetherapeutic drug injection (D9612).You asked the Plan to pre-approvetherapeutic drug injection. You say that this procedure is medically necessary and you feel that using IV sedation is best, as local anesthesia is proven to not have a great impact in numbing the area with the present infection.The Plan denied your request. The Plan says this is not covered under the plan benefits.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-approvetherapeutic drug injection (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, adult diapers (A4520).
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has medical conditions that
prevent the control of the bowels or bladder and ambulation. The use of adult diaper is considered necessary
rather than elective. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, adult
diapers (A4520).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308, 90792) provided on
November 6, 2019 to December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that the hospital staff should have obtained
authorization. The Plan denied your request. The Plan says these services were not authorized.
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 has network providers
available who can provide 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 for the nursing facility care (99308, 90792) provided
on November 6, 2019 to December 23, 2019 by an out of network (OON) provider.
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 the services are medically necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 you were medically stable with no evidence of need for supervision by a physical medicine andrehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current endurance and functional status and medical stability.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 pay for the comprehensive eye exam (92004) provided June 20, 2019.
You asked the Plan to pay for the vision services. You say that the records provided should support the
necessity of the service in dispute. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the member's terminal
condition. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the comprehensive eye exam (92004) provided June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two abutment supported retainers for porcelain/ceramic fixed partial denture (D6068 x2).
You asked the Plan to pre-approve the custom fabricated abutments and abutment supported retainers for porcelain/ceramic fixed partial denture. You say that you believe having no teeth on one side of your mouth would be a medical issue. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 two custom fabricated abutments (D6057 x2) and two abutment supported retainers for porcelain/ceramic fixed partial denture (D6068 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Phonak Lyric invisible hearing aids.You asked the Plan to pre-approvethe requested hearing aids. You say that these are the only hearing aids that work.The Plan denied your request. The Plan says the requested device is not on the list of covered hearing aids.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Although the plan offers a hearing aid benefitin excess of Medicare coverage, the requested items are not among those covered under this benefit.Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Phonak Lyric invisible hearing aids.