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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have 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 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 patient was admitted to the hospital for lumbar spinal surgery. The patient 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. Finally, there is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and bone
replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that you
cannot afford to pay for these services. 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. Therefore, we decided that the Plan does not have to pre-approve a
guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for foot surgery.

You asked the Plan to waive the coinsurance for the foot surgery. You say that the total charge before adjustments is unconscionable for a foot fracture. You say that you expected a $235 copayment not coinsurance. The Plan denied your request. The Plan says the coinsurance applied 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 for each covered surgery or observation room service in an outpatient hospital.

You have been asked to pay $3,438.80, which is 20% of the allowed amount for the foot surgery. The allowed amount is $17,194 (20% x $17,194 = $3,438.80). The foot surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for foot surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810) provided December 2, 2020 to December 9, 2020.
You asked the Plan to pay for the acupuncture services. You say that you thought you had unlimited acupuncture treatments. You don't know all the changes in the insurance plan to limit your treatments without your knowledge. The Plan denied your request. The Plan says the service exceeds the benefit maximum limitation of 24 visits per year.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The plan covers a maximum of 24 visits per year. We looked at your request, the records in the case file and rules. The records show that 24 acupuncture visits were provided from July 8, 2020 through November 30, 2020. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of acupuncture visits. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810) provided December 2, 2020 to December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle/foot orthosis.
You asked the Plan to pre-approve an ankle/foot orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item 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 an ankle/foot orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the requested item is needed for healing of a suspected tendon tear of foot and will help to promote healing and stability. The requested item appears to exceed your medical need. The documentation does not reveal evidence of instability on a physical examination. Therefore, you do not meet criteria for the requested item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ankle/foot orthosis. have not been met. Therefore, we decided that the Plan does not have to pre-approve an ankle/foot orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the endosteal implant. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 a surgical placement of implant body: endosteal implant (D6010).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction of a precancerous skin growth.

You asked the Plan to waive the copayment for the destruction of a precancerous skin growth. You say that you feel that you should only owe a $30 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received the destruction of a precancerous skin growth at an outpatient hospital facility. Therefore, you are responsible to pay $123.12, which is less than the $200 copayment.

You have been asked to pay $123.12 for the destruction of a precancerous skin growth. The destruction of a precancerous skin growth falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the destruction of a precancerous skin growth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom Sensor G4 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 the enrollee is not insulin-treated with multiple daily injections of insulin.

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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the case file indicates that the enrollee is not using insulin three or more times a day. The enrollee is checking the blood sugar three times a day. The elements of the local coverage determination are not satisfied. The requested service is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom Sensor G4 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 enrollee could have a serious function decline due to lack of access to aggressive therapies. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While the 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 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 acute 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 oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, panoramic x-ray, and Frenulectomy.

You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewing x-rays, panoramic x-ray, and Frenulectomy. You say that you would like some help paying for these services because you are on a limited income. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations had been exceeded.

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, comprehensive oral evaluation is limited to one procedure every three years, and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation and panoramic x-ray and your comprehensive oral evaluation benefit has been exhausted. The contract says that intraoral x-rays and bitewing x-rays are each limited to one procedure per calendar year. The record shows that you received intraoral x-rays and bitewing x-rays and your intraoral x-rays and bitewing x-rays benefits had been exhausted. The Plan contract also says that oral surgery is limited to two procedures per calendar year. The record shows that you received alveoloplasty procedure and your oral surgery benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, panoramic x-ray, and Frenulectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an interdisciplinary approach to rehabilitation, and his needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the denial of IRF care is correct.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met in a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services (CPT 15734) provided to the enrollee.

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 records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 15734 is "muscle, Myocutaneous, or Fasciocutaneous flap, from the trunk."

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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found in this case, the operative note indicates that the flap was incised at its inferior border and rotated and readvanced over the defect. No isolation of a flap was performed. The operative note describes undermining to achieve a complex closure.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for plastic surgery services (CPT 15734) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G4 platinum receiver 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 the enrollee is not being treated with multiple daily injections of insulin.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no justification for the monitor in the records. There is no evidence why the glucometer readings are insufficient. There is no evidence of how data leads to insulin dose adjustments. The enrollee is not taking multiple shots of insulin daily.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G4 platinum receiver for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for urgently needed services provided from April 29, 2020, to July 1, 2020.
You asked the Plan to waive the copayments for urgently needed services. You say that you did not receive the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for urgently needed services. The medical records show that you received urgently needed services on April 29, 2020. Therefore, you are responsible to pay the $50 copayment. The medical records show that you received urgently needed services on July 1, 2020. Therefore, you are responsible to pay the $50 copayment. The total amount you owe is: $100. You have been asked to pay the total copayment amount of $100 for urgently needed services. Urgently needed services fall within the urgently needed 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 copayments for urgently needed services provided from April 29, 2020, to July 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that the enrollee is need of skilled therapy, and cannot return home at this time. The Plan denied your request. The Plan says needs are custodial in nature.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health care services provided by a mental health counselor from February 19, 2020, to February 4, 2021.
You asked the Plan to pay for mental health care services. You say that you were not informed this provided would not take your insurance. The Plan denied your request. The Plan says this provider is not enrolled in and is not eligible to enroll in Medicare
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for mental health care services provided by a mental health counselor from February 19, 2020, to February 4, 2021.