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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found you underwent spinal surgery on May 20, 2021. The therapy notes state that you need assistance with bed mobility and transfers and walking 20 feet with a walker. You do not require the intensity of services in an IRF. Specifically, you do not require 15 hours per week of rehabilitative services and regular physician evaluation. The IRF services are not medically
necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unclassified drug injections performed on July 6, 2020 and reported with HCPCS code J3490.
You asked the Plan to pay for the unclassified drug injections. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Drugs must be reported with applicable drug administration codes. In this case, the HCPCS Code Manual definition of code J3490 is unclassified drug injections. We find that HCPCS code J3490 is not supported in the medical record. Specifically, the injectable drug code was reported without an applicable drug administration code. Based on this information, we decided that Medicare rules for coverage of the unclassified drug injections have not been met. Therefore, we decided that the Plan does not have to pay for the unclassified drug injections performed on July 6, 2020 and reported with HCPCS code J3490.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 14, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not request two ambulance services for your wife. 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 on October 14, 2020. 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 provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says the services are 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 the RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental/investigational procedure since it is the subject of ongoing clinical trials. Therefore, the request is considered 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 the RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
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 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for bleeding from PEG
tube site, congestive heart failure and a pleural effusion.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. There is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There a not 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on November 18, 2020.
You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist office visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. The Plan says that you had only reached $3280 for your out-of-pocket costs for the 2020 benefit year.
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 specialist office visits.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist office visit on November 18, 2020. The file also shows that you had only reached $3280 of the $3400 out-of-pocket costs for the 2020 benefit year. You have been asked to pay a $30 copayment for the specialist visit. The specialist visit falls within the Physicians/Practitioner 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 the specialist visit provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Dexcom CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you currently have a functioning CGM and the requested new CGM so you can set it with your Apple watch does not meet criteria.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a Freestyle Libre CGM. The Freestyle Libre CGM serves the same purpose as a Dexcom CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint blocks.

You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this 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 the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee failed to obtain significant pain relief from the prior injection and has alternate pain generators present. The request 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance (64625).
You asked the Plan to pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance. You say that this request is medically necessary. The Plan denied your request. The Plan says this service is currently considered experimental and investigational.
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 radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found this procedure is considered an experimental/ investigational procedure due to the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is considered not medically reasonable or necessary 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 radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for frames (V2020), lenses (V2300 x2), polycarbonate lens (V2784), and anti-reflective coating (V2750) received on August 18, 2020.
You asked the Plan to pay an additional amount for frames, lenses, polycarbonate lens, and anti-reflective coating. You say that you were not aware that you had exceeded the benefit limit. The Plan denied your request. The Plan says the benefits were applied correctly. The benefit allowance of $200 was applied to the purchase leaving a member responsibility of $638.
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 a $200 allowance, then you are responsible for paying the difference. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames, lenses, polycarbonate lens, and anti-reflective coating have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $200 and are therefore, responsible for paying the remainder of $638. Therefore, we decided that the Plan does not have to pay an additional amount for frames (V2020), lenses (V2300 x2), polycarbonate lens (V2784), and anti-reflective coating (V2750) received on August 18, 2020.
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 these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at a lower level of 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 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lower extremity
bacteremia and cellulitis. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. 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. 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. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the unilateral breast ultrasound (76641) provided December 14, 2020.
You asked the Plan to waive the copayment for the diagnostic service. You say that 76641 unilateral breast ultrasound is a preventative test for early detection of cancer. You were told that you would be billed for no more than $50. You are not able to pay $160 which is more than 3 times the estimated amount. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $160 copayment for each radiological diagnostic service. You have been asked to pay $160 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 unilateral breast ultrasound (76641) provided December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on January 7, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services you received on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) and the unspecified
preventive service (D1999) provided on December 21, 2020.
You asked the Plan to pay for the dental services. You say that this was a simple tooth extraction. You say that
this should be covered under your dental coverage. The Plan denied your request. The Plan says extraction is
not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered
service either.
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
surgical extraction (D7210) and the unspecified preventive service (D1999) provided on December 21, 2020.
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 would benefit from intensive rehab services. The Plan denied your request. The Plan says criteria for IRF care 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 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 was admitted to the hospital due to left sided weakness and found to have had a stroke. 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 inpatient rehabilitation facility (IRF) admission and services.
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says you do not not have complex nursing or medical needs requiring a resource intensive inpatient hospital 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex
nursing or rehabilitation needs. 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.