Persius/hicric huggingface dataset:
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 has a past medical history of memory problems, heart disease and diabetes and is living at home. The enrollee is having increased weakness and frequent falls. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eyewear you received on June 25, 2020, and August 26, 2020.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has been reached.
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 up to $150 per calendar year. We looked at the file and the Plan's rules. The records show that the Plan paid $150 toward your routine eyewear for 2020. You are responsible for any amount over the $150 benefit limit. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the routine eyewear you received on June 25, 2020, and August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provide on June 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 17, 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 the services provide on June 7, 2019.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee was admitted to the hospital with pneumonia due to COVID19 and an acute kidney injury. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on November 15, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you say that you were taken to the wrong hospital. You say you are being charged for the second ambulance trip. 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Since an ambulance trip was provided, the correct copayment has been applied. 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 November 15, 2020.
We note your complaint about being taken to the wrong hospital resulting in a second ambulance trip. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on August 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 for skilled nursing services provided on August 31, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic - porcelain/ceramic and the retainer crown - porcelain/ceramic.
You asked the Plan to pay for the pontic and the retainer crown. You say that you need replacement bridges. The Plan denied your request. The Plan says the pontic and retainer crown are not covered 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 pay for the pontic - porcelain/ceramic and the retainer crown - porcelain/ceramic.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage beyond the fifty (50) mile limit.
You asked the Plan to pre-approve additional routine transportation mileage. You say that you require additional routine transportation mileage to attend medical appointments. The Plan denied your request. The Plan says the service is a covered benefit, but your request exceeds mileage limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Anything beyond the 50 miles is not a covered benefit. The health plan contract says each one-way routine transportation trip must not exceed 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage beyond the fifty (50) mile limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided on August 21, 2020 to August 24, 2020.
You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized. The inpatient mental health benefit was exhausted at the time services were 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Furthermore, the record shows that the member did not have a 60-day break in stay and has been admitted at least once a month to either inpatient or behavioral health since September 2019. The inpatient mental health benefit was exhausted at the time services were provided. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided on August 21, 2020 to August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fornew glasses purchased on November 13, 2020.You asked the Plan to pay forthe services. You say that no one advised you that you were just a month short of the require time.The Plan denied your request. The Plan says the benefit was exhausted.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 eyewear with a $100 benefit every two years.We looked at the file and the Plan's rules. The plan paid the eyewear benefit on January 17, 2019. November 13, 2020 is less than two years from this date. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay fornew glasses purchased on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have waive the cost-sharing for the periodontal scaling and root planing (D4341), complete series of radiographic images (D0210), and comprehensive oral evaluation (D0150) provided October 13, 2020, by an out-of-network (OON) provider.
You asked the Plan waive the cost-sharing for the periodontal scaling and root planing, complete series of X-rays and comprehensive oral evaluation. You say that you called and were told the services were covered in full. The Plan denied your request. The Plan says the services were provided by an OON provider and the cost-sharing was applied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodontal scaling and root planing, complete series of X-rays and comprehensive oral evaluation when the services are medically necessary and reasonable. The contract also say that you must pay a 50% coinsurance for a comprehensive oral evaluation and intraoral x-rays when provided out-of-network. Additionally, it says that you have a 75% coinsurance for Periodontal scaling and root planning when provided out-of-network. You have been asked to pay $109.50 ($146 allowed amount x 75% coinsurance = $109.50) for the periodontal scaling and root planning, $53 ($106 allowed amount x 50% coinsurance = $53) for the complete series of x-rays and $29 ($58 allowed amount x 50% coinsurance = $29) for the comprehensive oral exam for a total cost share of $236.50. 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 waive the cost-sharing for the periodontal scaling and root planing (D4341), complete series of radiographic images (D0210), and comprehensive oral evaluation (D0150) provided October 13, 2020.
Your complaint about a plan representative potentially providing misinformation about the cost of services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT code 74183), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your request. The Plan says repeat imaging may be supported for one of the following reasons: Results of prior imaging showed signs (evidence) that the enrollee's problem (condition) has progressed or recurred and repeat imaging would affect how the enrollee's doctor is managing the enrollee's problem (condition). The Plan states the enrollee's records do not show that one of these applies to the enrollee.
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 the MRI. Our physician reviewer found repeat imaging may be supported for one of the following reasons. -Results of prior imaging showed signs (evidence) that the enrollee's problem (condition) has progressed or recurred. -Repeat imaging would affect how the enrollee's provider is managing the member's problem (condition). The enrollee's records do not show that one of these applies to the enrollee. The enrollee's records show that the same study or a test like it has been done for the enrollee. They also show the results of this test. The prior study showed the enrollee's provider what they needed to see in order to treat the enrollee's condition. Repeat imaging is not supported without results of prior imaging that show a clear reason for it. In this case, based on the review of medical records, the enrollee's clinical circumstances do not meet medical policy or NCD guidelines for coverage of acquired cystic disease. Based on the standard of care, the enrollee could undergo ultrasound of the kidneys for follow-up of acquired renal cysts in native kidneys. The review has determined that the requested MRI is not medically reasonable and 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT code 74183), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says this provider is out-of-network. The Plan states they are approving the DME to be provided by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) to be provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on September 14, 2020.
You asked the Plan to pay for the physician service. You say that that the enrollee advised that he revoked hospice state so that he was able to go to the emergency room. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 14, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Foresee Home AMD monitoring program for visual field assessment (0379T).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that home monitoring of the patient's macular degeneration with Foreseehome is not medically necessary. In this case, the patient has bilateral early nonexudative macular degeneration. The standard of care in this situation is oral AREDS formula vitamins, home monitoring with AMSLER grid, and intermittent follow-up examinations. The Foreseehome monitoring system has been evaluated and validated by prospective analysis and has been shown to be a safe and effective system for exudative macular degeneration surveillance for high-risk individuals in a relatively limited study. In the context of mild nonexudative macular degeneration that is being actively treated and monitored with examination and imaging, it is not the standard of care for treatment or monitoring. Overall, the Foreseehome system may be more effective than the Amsler grid, but only a single study of a relatively short duration (1.4 years of mean follow-up) exists to compare the efficacy. There is no evidence that the Foreseehome system improves disease outcomes, or that it would be superior for treatment of the patient's mild non-exudative macular degeneration as compared with standard treatments. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Foresee Home AMD monitoring program for visual field assessment (0379T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on October 30, 2020.
You asked the Plan to pay for the home visit. You say that the enrollee was referred by the attending physician at the nursing facility who granted you privileges to provide necessary medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 home visit provided by an out-of-network provider on October 30, 2020.