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

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that 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 a stroke with right sided weakness. His 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.

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 an 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 crown (D2740).

You asked the Plan to pay for the crown. You say that you would like reconsideration because the dental office
showed you what your portion of the payment for this service would be. The Plan denied your request. The
Plan says this 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, 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 crown
(D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating specialist.

You asked the Plan to waive the copayment for specialist services. You say that you are being charged two copayments. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services/specialist visit.

You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist visit 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 specialist services provided by a participating specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physical exam (99387).

You asked the Plan to pay for the physical exam. You say that this visit should be covered. The Plan denied your request. The Plan says the benefit for this type of exam was exhausted at the time the service was rendered.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an annual wellness visit once every 12 months. The plan covers one comprehensive physical exam every year.

The file shows that a complete physical exam. The benefit for physical exams is limited to one annually. The benefit was exhausted at the time of the visit. Therefore, we decided that the Plan does not have to pay for a physical exam (99387).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-rays (D0210) and the scaling for gingival inflammation (D4346).

You asked the Plan to pay for the dental services. You say that it had been over a year since you had been to the dentist. You say that this was your first time seeing this dentist. You say that new x-rays had to be done. You also say that you needed the scaling done to remove accumulated tartar. The Plan denied your request. The Plan says complete series x-rays is not listed as a covered service. The Plan also says scaling for gingival irrigation is not listed as a covered service.

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 complete series x-rays (D0210) and the scaling for gingival inflammation (D4346).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear you received.

You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says this is not a covered benefit.

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 only routine eye exams. Eyewear is not covered under your supplemental vision benefit.

We looked at the file and the Plan's rules. Eyewear is not covered under your supplemental vision benefit. This benefit only covers routine eye exams. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear you received.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Ultrasound study of arteries of both arms and legs, complete (93923).

You asked the Plan to waive the copayment for the Ultrasound study of arteries. You say that you think your claim should be processed with a lower copayment. The Plan denied your request. The Plan says the copayment was 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 $150 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility.

You have been asked to pay $106.10 as your copayment for the Ultrasound study of arteries. This 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 Ultrasound study of arteries of both arms and legs, complete (93923).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply for a CGM (K0553).

You asked the Plan to pay for a supply for a CGM. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. No medical records were provided in this case. Based on this information, we decided that Medicare rules for payment for a supply for a CGM have not been met. Therefore, we decided that the Plan does not have to pay for a supply for a CGM (K0553).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips to dialysis appointments.

You asked the Plan to pre-approve routine transport. You say that you need help with transportation to dialysis, and it is very stressful trying to find people to take you to your appointments. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this request is not for transportation immediately following inpatient hospital or skilled nursing facility discharge.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 30 days immediately following inpatient hospital discharges or skilled nursing facility stays.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips to dialysis appointments.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of lumbar stenosis have not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The device is experimental. More research is needed to show safety and efficacy of the interspinous process devices. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313, E2377, E2311, K0108, E2300).

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for multiple power options.

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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has any medical need for the remaining requested accessories (E2313 and E2377). E2311, K0108, E2300 are not covered as they serve no medical purpose.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313, E2377, E2311, K0108, E2300).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services provided by an out-of-network provider.

You asked the Plan to pay for laboratory services. You say that no in-network surgeon would take a new case
during the pandemic. You say that this was an urgent biopsy for a growth on your tongue. The Plan denied
your request. The Plan says the provider is not in-network.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There were no records requested to determine whether the services were
urgently needed. Also, there was no information submitted showing there were in-network providers available.
Therefore, we decided that the Plan has to pay for laboratory services provided by an out-of-network provider.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography colonography (CTC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that screening computed tomographic colonography (CTC) is non-covered. 

We looked at the file and Medicare rules. The requested services are a screening CTC. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a computed tomography colonography (CTC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).

You asked the Plan to pre-approve these services. 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. Medicare rules say that a Group 3 PWC is covered when specific criteria are met.

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 these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the records show that the enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer. The Group 3 PWC is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges
because this was a telehealth visit. 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 specialist visits.

You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the continued SNF care. You say that you do not believe that you are ready to leave the facility. The Plan denied your request. The Plan says you no longer require daily skilled services. Your needs can be met in the home health setting.

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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was treated in the hospital with a right hip fracture, treated surgically. She was admitted to the SNF. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was treated for pain with effect. Her lungs were clear. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By the dates in question, the beneficiary was at a supervision to independent level with functional mobility including gait to 150 feet with a rolling walker. The beneficiary required varying assist with daily living activities.

There are no identifiable skilled therapy service needs. There are no identifiable skilled nursing service needs. This beneficiary does not meet severity of illness or intensity of service criteria for a continued inpatient stay 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
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 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 urinary tract infection, pneumonia and anemia. 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.