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

We decided that the Plan does not have to pay for the inpatient hospital services.

You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We looked at the file and Medicare rules. No records were submitted to support that the services were medically necessary for the enrollee. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services.
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 this was an emergency. 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. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an optometry office visit.

You asked the Plan to waive the copayment for office visit. You say that you are appealing this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $30 copayment for specialist visit.

You have been asked to pay $30 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 optometry office visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator (CPT code E0760).

You asked the Plan to pre-approve the stimulator. You say that you are currently in a boot and have difficulty
walking. The Plan denied your request. The Plan says your records show you do not have x-rays 90 days apart
showing no healing.

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 stimulator. Our physician reviewer
found based on the medical records provided there is no documentation that you meet the requirements listed in
the LCD: Osteogenesis Stimulators (L33796) for Medicare coverage. Two x-ray reports are included in the
records: reportedly show a fracture of the proximal shaft of the left third metatarsal; the x-rays reportedly show 
no fracture in the left foot. The records do not include the following information: "Nonunion of a fracture documented 
by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated 
by a minimum of 90 days. Each radiograph set must include multiple views of the fracture site accompanied by a written interpretation by a treating practitioner stating that there has been no clinically significant evidence of fracture healing 
between the two sets of radiographs."

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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve osteogenesis stimulator (CPT code E0760).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section.

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 seizures, metabolic encephalopathy, acute renal failure, and sepsis. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen
and pelvis.

You asked the Plan to pre-approve MRI. You say that you are requesting this MRI so you can assess the mass
in the enrollee's kidney. The Plan denied your request. The Plan says the denial of authorization for this testing
is correct, because the information provided does not describe signs or symptoms to warrant this imaging.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee
had an MRI scan in 2020 which was a post-treatment and reportedly not much change in size or
changes of cryoablation were noted on the kidney with some stranding around it, but the imaging was not able
to tell if there was any recurrence. The clinical information provided does not show that recurrence is
suspected. Per guidelines for abdominal and pelvis MRI, the need for additional imagine following ablative
technique is indicated once 3 to 6 months post-operatively, then annually for 5 years. Therefore, the requested
MRI is not medically reasonable or 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 MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve Magnetic Resonance Imaging (MRI) of the abdomen and pelvis.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the transrectal ultrasound.

You asked the Plan to waive the coinsurance for the transrectal ultrasound. You say that you shouldn't have to pay separate cost sharing for this procedure since you already paid an office visit copayment. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance up to $75 per day for diagnostic radiology services.

You have been asked to pay 20% coinsurance for the transrectal ultrasound. The transrectal ultrasound falls within the diagnostic radiology services benefit category. This is a separate and distinct service from an office visit, so separate cost sharing applies. 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 transrectal ultrasound.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) with altered mental status and failure to maintain adequate oral intake, resulting in protein calorie malnutrition and risk of refeeding syndrome. The records support a reasonable expectation that the enrollee would require at least two midnights of inpatient hospital care, including earlier ED 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker (CPT code 33274), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The rules say leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. There is no documentation supporting the enrollee is participating in an approved CED study. Therefore, we decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker (CPT code 33274), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an O2 concentrator provided by an out of network (OON) provider.

You asked the Plan to pay for an O2 concentrator. You say that the item should be covered. The Plan denied your request. The Plan says you received the item out-of-network.

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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for an O2 concentrator provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you are asking for reconsideration of the denial of this inpatient claim. This claim met clinical indications for admission to inpatient care under MCG's 23rd Edition guidelines, Gastrointestinal Bleeding, Upping (M-180). The Plan denied your request. The Plan says that the documentation provided does not support the need for an inpatient admission. Observation level of care was approved.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case the enrollee has a significant cardiac history as well as cardiac symptomatology. Furthermore, the enrollee had at least two other issues, namely evidence of gallbladder disease and possible gastrointestinal bleeding based on heme positive stool and being on antiplatelet therapy. A physician in this case would have a reasonable expectation that the hospital stay would span two midnights. The elements of the controlling criteria have been satisfied. Therefore, coverage at an inpatient level of care is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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 pay for the filling (D2392).

You asked the Plan to pay for the dental service. You say that you have been with this plan for many years. You say that you were never advised that your dentist's status with your plan had changed. You say that your coverage clearly states that you can see any dentist. You also say that you feel that this denial is unfair. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made to providers who have opted out of Medicare.

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 that you receive from a provider who has opted out of Medicare are not covered under this benefit. The Evidence of Coverage clearly states that if you use a provider that has opted out of Medicare you will not receive reimbursement. Therefore, we decided that the Plan does not have to pay for the filling (D2392).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychotherapy services (90791, 90837).

You asked the Plan to waive the copayment for the psychotherapy services. You say that you were dissatisfied with the level of care provided and stated that you were harassed by this provider after terminating care. The Plan denied your request. The Plan says this copayment was applied directly, but your complaint will be reviewed in a separate department.

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 $30 copayment for each individual outpatient mental health service.

You have been asked to pay a $30 copayment for each session of psychotherapy services. 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 psychotherapy services (90791, 90837).

Your complaint about the services provided and potential harassment by a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for FlowerAmnioFlo.

You asked the Plan to pay for FlowerAmnioFlo. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the clinical value and effectiveness of FlowerAmnioFlo has not been demonstrated in the setting of plantar fascial fibromatosis.

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 pay for FlowerAmnioFlo. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical value and effectiveness of FlowerAmnioFlo in the setting of plantar fascial fibromatosis has not been demonstrated in peer-reviewed literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FlowerAmnioFlo have not been met. Therefore, we decided that the Plan does not have to pay for FlowerAmnioFlo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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 in the Medicare rules section.
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 based on the documentation provided, the health plan's denial should be upheld. The
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
require fifteen hours per week of rehabilitative services and 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section.

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of respiratory failure and idiopathic pulmonary fibrosis. The enrollee is living at home and has weakness and declining function. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 acute IRF admission and services.