Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care services provided on February 17, 2020 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing care services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained for these services.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 skilled nursing care services provided on February 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has not tried conservative therapy, and has pain down his legs.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has low back pain, and bilateral leg pain. The pain is described in the MRI report as radicular pain to the right hip and thigh. The enrollee previously underwent interlaminar and sacroiliac injections. The interlaminar injections provided a 2-month resolution of symptoms. The enrollee is described as not a candidate for anti-inflammatory medications. There is a lack of documentation of a trial of Acetaminophen for pain. Nor is there documentation of other conservative therapies, such as a trial of physical therapy. The requested procedure is supported for predominantly axial pain that is not associated with radiculopathy or neurogenic claudication. Radiculopathy is documented in the provided notes. As well, the requested procedure is supported for those that have had at least 3 months of moderate to severe pain with functional impairment and pain that is inadequately responsive to conservative care. An adequate trial of physical therapy and Acetaminophen is not documented in the provided office notes. Based on the rules and records provided, the enrollee does not meet the coverage criteria for the requested injections. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair.

You asked the Plan to pre-approve the requested wheelchair. You say that you recently had a heart attack, and have very limited mobility. The Plan denied your request. The Plan says you have  epilepsy, which is not well-controlled.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 requested wheelchair. Our physician reviewer found that your previous wheelchair was hit by a car and is no longer a consistent, safe means of mobility. The records indicate there is a documented seizure disorder. It is not clear that you can safely navigate the requested wheelchair. The provision of a Group 3 wheelchair would be indicated after you are cleared by a neurologist showing that your seizures are under control and do not pose a safety issue.  As such, this request is not medically 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 the requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 9, 2020 to January 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network 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 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 January 9, 2020 to January 25, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 26, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that it was necessary to call the ambulance. You say that the balance should be paid.The Plan denied your request. The Plan says the copayment 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 a $250 copayment for each one-way Medicare-covered ground trip.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 ambulance transport provided on December 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from November 9, 2019 through November 10, 2019.
You asked the Plan to pay for SNF care. You say that the stay was 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 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 SNF care. 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 beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from November 9, 2019 through November 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on March 11, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you were not informed you would owe
a copayment and cannot afford the charges. 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 $175
copayment for CT scans.
You have been asked to pay a $175 copayment for a CT scan. A CT scan 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 a CT scan provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued services using a BiPAP device.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says there is no information showing the enrollee is using the BiPAP machine.
The Plan follows Medicare rules. Medicare rules say that positive airway pressure devices are only covered under certain medical indications. 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 continued services. Our physician reviewer found that you have obstructive sleep apnea, and have been treated with a BiPAP device. However, compliance data indicates that you are not using the device. The minimum usage criteria of at least 4 hours per day for at least 70% of days is not met. Therefore BiPAP is considered 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued services using a bi-level positive airway pressure (BiPAP) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing of four or more teeth per quadrant and periodontal scaling and root planing of one to three teeth per quadrant provided on February 3, 2020.You asked the Plan to pay for the periodontal scalings and root planings. You say that your dentist told you that the Plan would cover half of these services according to a quote from last year.The Plan denied your request. The Plan says these services 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 periodontal scaling and root planing of four or more teeth per quadrant and periodontal scaling and root planing of one to three teeth per quadrant provided on February 3, 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 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 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 documentation does not support that there are significant, or complex medical/nursing issues that are required to be provided in the IRF setting. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program provided in the IRF. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 2, 2019 through December 17, 2019 and December 22, 2019 through December 31, 2019.You asked the Plan to pay forSNF care. You say that the stay was 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 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 SNF care. 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 beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from December 2, 2019 through December 17, 2019 and December 22, 2019 through December 31, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from February 13, 2020 through February 26, 2020. You asked the Plan to pay for SNF care. You say that the stay was 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from February 13, 2020 through February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and cores in addition to crowns (D2954) for tooth #'s 23 & 25 and crowns (D2750) for tooth #'s 23 & 25. You asked the Plan to pre-approve the prefabricated post and cores and crowns. You say that these services are important to hold the new denture that is being provided for the lack of support in your teeth. The Plan denied your request. The Plan says placing post and cores and crowns on teeth #23 and #25 is not reasonable or necessary, and does not meet the coverage criteria under your supplemental 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. The Plan covers the prefabricated post and cores and crowns when the services are medically necessary and reasonable. 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 prefabricated post and cores and crowns. Our reviewer says that the services are not medically necessary. Our physician reviewer found the two teeth in question have prior endodontic treatment and both suffer from periodontal disease with approximately 50% bone loss. The opposing arch is edentulous. Our reviewer found that tooth #25 has only endodontic access, and the tooth otherwise is intact. Tooth #23 has a large distal restoration, but the remainder of the tooth including the incisal edge is intact. In addition, both teeth have significant periodontal involvement. Neither of these teeth have sufficient missing structure to qualify for a crown restoration under the criteria. Our physician reviewer also found that as the crowns are not medically necessary, the post and cores are also not medically necessary, as they are only necessary when there is insufficient structure to retain a crown where indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the prefabricated post and cores and crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve prefabricated post and cores in addition to crowns (D2954) for tooth #'s 23 & 25 and crowns (D2750) for tooth #'s 23 & 25.
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 can safely receive the services needed in other settings.
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. 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient did not have significant post operative complications. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires an 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on February 12, 2020.
You asked the Plan to waive the copayment for an epidural injection. You say that this should be considered a Tier 1 procedure and you should only owe a $150 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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received an epidural injection at an outpatient hospital facility on February 12, 2020. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $250 copayment. You have been asked to pay a $250 copayment for an epidural injection. An epidural injection falls within the outpatient surgery and other medical 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 an epidural injection provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick external catheter.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the notes do not show that a standard external catheter will not meet the enrollee's needs.
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 requested device. Our physician reviewer found that the enrollee has a past medical history of hydrocephalus, dementia and MRSA pneumonia with respiratory failure. The submitted medical records include a discharge summary from short term acute care to long term acute care, which does not address any need for an external female catheter system. Therefore, the requested device is not medically reasonable and necessary to treat the enrollee. 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Purewick external catheter.