Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co payments for the services you received.

You asked the Plan to waive the services. The Plan denied your request. The Plan says you are responsible for the cost share.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co  payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 co payment for outpatient surgery, a $35 co payment for Medicare-covered eye exams, and a $15 co payment for physician services.

Review of the file shows that you had two surgical procedures, an eye exam, and physician 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 co payments for the services you received
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 the enrollee does not meet criteria for coverage of IRF care.
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 there are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Imaging
Decision: Favorable

We decided that the Plan has to provide coverage fora positron emission tomography (PET) scan.You asked the Plan to provide coverage fora PET scan. You say that a PET scan is medically necessary.The Plan denied your request. The Plan says that Medicare coverage criteria are not met.The Plan must follow Medicare rules. Medicare rules say that PET scans 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 provide coverage for a PET scan. Our reviewer says that Medicare coverage criteria are met.  Our physician reviewer found t is medically appropriate for the workup of Alzheimer's in this enrollee to include a PET scan. There are multiple medical studies that have demonstrated the utility of PET scan in the evaluation of Alzheimer's disease and the distinguishing cues found on PET scans of those suspicious for Alzheimer's disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have been met. Therefore, we decided that the Plan has to provide coverage fora positron emission tomography (PET) scan.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 toopen the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that SNF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNFwhen the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found theenrollee does not require skilled nursing or therapy services on a daily basis.  This 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe frame and lenses (V2100) provided on July 30, 2020.You asked the Plan to pay forthe frame and lenses. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says you have exceeded the maximum benefit limit.Medicare generally does not cover routine vision and eyewearservices. 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 provided an allowance of $150 every year for these services.We looked at the file and the Plan's rules. You previously used the full $150 benefit in April 2020 for eyewear. Based on this information, we decided that the Plan's rules for coverage of the frame and lenses have not been met.Therefore, we decided that the Plan does not have to pay forthe frame and lenses (V2100) provided on July 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespine surgery with an interlaminar device.You asked the Plan to pre-approvespine surgery with an interlaminar device. You say that the services are medically necessary.The Plan denied your request. The Plan says you do not meet criteria for this service.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 spine surgery with an interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery with an interlaminar device have not been met.Therefore, we decided that the Plan does not have topre-approvespine surgery with an interlaminar device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that this provider shouldn't be penalized for the facility's failure to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 medical services provided on March 31, 2020 by an out of network (OON) provider.
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 for the enrollee.
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 Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to preapprove
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 is a 75-year-old woman
with a history of heart disease, stroke, peripheral vascular disease, Crohn's disease, and rheumatoid arthritis.
The enrollee has a 6-week history of progressive weakness and falls. The enrollee has been getting therapy at
home. The enrollee ambulates 30 feet with RW within the home. The documentation does not support that the
complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. The documentation does not support that this enrollee
requires at least 3 hours a day /5 day a week, or 15 hours over 7 consecutive days, of therapy services.
Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF)
admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925).
You asked the Plan to pre-approve a duplex scan of lower extremity arteries. You say that this is medically
necessary. The Plan denied your request. The Plan says the enrollee has not had the required ABI testing.
The Plan must follow Medicare rules. Medicare rules say that an ABI should be abnormal, e.g., less than 0.9 at
rest, and accompanied by other appropriate indications before proceeding to additional studies.
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has had
an abnormal ABI. Based on this information, we decided that Medicare rules for coverage of a duplex scan of
lower extremity arteries have not been met. Therefore, we decided that the Plan does not have to pre-approve a
duplex scan of lower extremity arteries (93925).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) services.
You asked the Plan to pre-approve the MRA. You say that the records provided support the need for an MRA.
The Plan denied your request. The Plan says there is insufficient clinical information to approve the requested study.
The Plan follows Medicare rules. Medicare rules say that an MRA of the head/neck is covered when 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 MRA. Our reviewer says that the
requested MRA is not medically necessary. Our physician reviewer found the enrollee had complaints of
memory problems. Their provider ordered both an MRI and MRA of the brain (in addition to other tests). The
enrollee had nothing in their history, complaints or exam findings to suggest the presence of a condition
involving the head and/or neck for which surgery would be anticipated. There was nothing present to suggest
the presence of a tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis.
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 MRA have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance angiography (MRA) services.
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 enrollee had a fall and needs IRF care in order to be as independent as possible.The Plandenied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to be able to currently perform fifteen hours per week of rehabilitative services with 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapproveFreestyle Libre 14 day Sensor Continuous Glucose Monitoring (CGM).You asked the Plan to preapprovethe CGM. You say that the enrollee really requires this device.The Plan denied your request. The Plan says you do not meet coverage criteria because you do not frequently adjust insulin treatment regimen based on the test results of monitoring.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to preapproveFreestyle Libre 14 day Sensor Continuous Glucose Monitoring (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental services (D2950) described as core buildup.You asked the Plan to pre-approvethese services. You say that this service is medically necessary.The Plan denied your request. The Plan sayswhile portion of the requested services were approved, code D2950 is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, code D2950 is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approvedental services (D2950) described as core buildup
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.Youasked the Plan to pre-approvethe LTACH services. You say that this transfer is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that LTACHservices 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 thePlan 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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-termacute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care.The requested LTACH services are not medically necessary,reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services havenot been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora TENS unit (E0745) provided to the enrollee on June 3, 2020.You asked the Plan to pay forthe TENs units. You say that the claim should be paid.The Plandenied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery and relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. Therefore, the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fora TENS unit (E0745) provided to the enrollee on June 3, 2020.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe services. We decided that the Plan does not have to pre-approveambulance transport. You asked the Plan to pre-approve the services. 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We decided that the Planhas to pre-approvethe services. The Plan doctor is stating they approved the authorization through December 14, 2020, for the SNF, they also say since you have a PPO you can request transfer to another facility. The Plan has not provided due diligence in answer to our request for more information, their response was unclear and did not actually answer the question, therefore, we are overturning the SNF services based on lack of information provided by the Plan.Therefore, we decided that the Plan has to pre-approvethe services. We also decided that the Plandoes not have to pre-approvethe ambulance transport.We are upholding the ambulance transport because there is no medical reason for you to transfer. Therefore, we decided that the Plan does not have to pre-approve.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 a crown (D2780) provided on October 1, 2020.
You asked the Plan to pay for a crown. You say that the service should be covered. The Plan denied your request. The Plan says the service rendered is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Any service not listed on the Plan's EOC is not covered. 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. Specifically, you received a service that is not listed in the Plan's EOC as a covered benefit. Therefore, we decided that the Plan does not have to pay for a crown (D2780) provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the extraction (D7210), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided from January 8, 2020, to February 5, 2020.You asked the Plan to pay forthe dental services. You say that the services were medically necessary.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that care rendered by a provider that is not part of our supplemental dental network is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, carerendered by a provider that is not part of our supplemental dental network is not covered.Therefore, wedecided that the Plan does not have to pay forthe limited oral evaluation (D0140), the extraction (D7210), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided from January 8, 2020, to February 5, 2020