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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services 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 the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include tracheostomy care with ventilator support, neurologic montoring, surveillance laboratory studies, intravenous antibiotics, C. Diff precautions, tube feeding, and therapy services. 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 he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2751) for tooth # 3 provided on September 21, 2019.
You asked the Plan to pay for the dental service. You say that you were advised everything would be covered. You say that you were advised you were able to get the service. You also say that you cannot afford to pay for the service. The Plan denied your request. The Plan says the frequency limit for crowns has been exceeded. The Plan also says that crowns are limited to coverage once in a 5 year period.
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 and crowns are a covered service, the frequency limit has been exceeded. The records shows that the Plan previously paid for a crown for tooth # 3 on March 29, 2017. Therefore, we decided that the Plan does not have to pay for the crown (D2751) for tooth # 3 provided on September 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topre-approve bathtub rail bars You asked the Plan to pre-approvethe bathtub rail bars. The Plan denied your request. The Plan says the item in dispute is a self-help device and is not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvebathtub rail bars
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 feel that the service should be covered because you are very sick and needs the help and therapy because you are not able to get in and out of the house. The Plan denied your request. The Plan says the Medicare criteria for IRF level of coverage was 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 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 is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the pulpal debridement (D3221 x 2), and abutment
supported porcelain crown (D6058 x 2) provided on October 2, 2019.

You asked the Plan to reimburse you for the dental services. You say that the services were emergent. The Plan
denied your request. The Plan says the services you received are not listed as covered services.

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 dental services that you received
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse
you for the pulpal debridement (D3221 x 2), and abutment supported porcelain crown (D6058 x 2) provided on
October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the prophylaxis (D1110) provided on July 30, 2019.You asked the Plan to pay forthe dental services. You say that you became a participating provider on August 1, 2019. You say that you would like an exception to be made as the services were provided to the enrolled 1 day prior.The Plan denied your request. The Plan says you knew you were not credentialed at the time the services were rendered to the enrollee. The Plan says you did not become participating with the Plan until August 1, 2019. The Plan also says that services received out of network are 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 and the dental services you received are listed as covered, dental services are not covered when they are provided out of network.Therefore, we decided thatthe Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the prophylaxis (D1110) provided on July 30, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 15, 2019 by out of network provider.
You asked the Plan to pay for the ambulance services. You say that the service was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
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 ambulance services provided on May 15, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220), and the additional intraoral x-ray (D0230) provided on August 20, 2019.
You asked the Plan to pay for the intraoral x-rays. You say that you were not informed you would have to pay for the service before you received it. You also say that you were not informed that the panoramic x-ray would not be covered. You also say that you should have had the option as to whether or not you wanted the x-rays. The Plan denied your request. The Plan says intraoral x-rays are not listed as covered services.
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, intraoral x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray (D0220), and the additional intraoral x-ray (D0230) provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown (D6750), and the pontic (D6240) provided on August 26, 2019.
You asked the Plan to pay for the dental services. You say that you had a dental accident in October 2019. You also say that you were advised by the Plan that you would be fully reimbursed for the services. The Plan denied your request. The Plan says the retainer crown and pontic are not listed as covered services. The Plan says you were notified prior to receiving the services that they would not be 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, the retainer crown and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6750), and the pontic (D6240) provided on August 26, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health care services.You asked the Plan to pre-approvehome health care services. You say that the requested home health care services are medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria.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 notmade reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records in order to determine if the enrollee meets Medicare criteria for the requested home health care services. The case file indicates that the Plan did not request any records.Therefore, we decided that the Plan has to pre-approvehome health care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on August 28, 2019.
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you were not advised that this provider was out-of-network. The Plan denied your request. The Plan says these services were performed by a non-participating provider.
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, your contract clearly states that there is a 50% coinsurance for both periodic oral exams and prophylaxes when they are received out-of-network. The record shows that you saw an out-of-network provider, and the Plan is not obligated to pay the in-network benefit rates for the periodic oral evaluation and prophylaxis. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on August 28, 2019.
Your complaint about being unhappy about this dental claim is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 3, 2019 by out of
network provider
You asked the Plan to pay for the Magnetic Resonance Imaging. You say that services were medically
necessary. The Plan denied your request. The Plan says the services were provided out-of-network, were not
emergent and were not pre-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 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 October 3, 2019
by out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for these compression stockings is correct, because they do not meet the definition of a surgical dressing and you are not being treated for a venous stasis ulcer.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 25, 2019. You asked the Plan to pay forthe lab services. You say that the services were provided to the enrollee at the request of an in network provider.The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve vthe SNF admission. You say that the enrollee needs SNF care because is not yet 100% independent which is necessary for her to go home.The Plan denied your request. The Plan says daily skilled services are not required. The care needed is mainly custodial.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 pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was treated for influenza with other respiratory issues and chest pain. She is currently admitted to the hospital for observational care. Cardiac testing is negative and she currently has no shortness of breath. There is an appeal for the denial of a SNF admission. This patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require these skilled nursing or skilled therapy services 
(or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 9, 2019 by the out of network provider. You asked the Plan to pay forthe radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were out-of-network and there was no prior authorization.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 September 9, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe annual wellness visit provided on August 22, 2019.You asked the Plan to waive the coinsurance forthe annual wellness visit. You say that this was for anwellness exam. You say that you were informed the doctor is an approved provider.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for an out-of-network annual wellness visit.You have been asked to pay $79.46, which is less than the standard 30% coinsurancefor theout-of-networkannual wellness visit. The annual wellness visit falls within the "Annual Wellness Visit" benefit category. The records show that the provider is out-of-network. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe annual wellness visit provided on August 22, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (G0463)
provided August 31, 2019 by the provider.

You asked the Plan to waive the copayment for the emergency room services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for Emergency Care.

The enrollee has been asked to pay a $76.75 copayment for the emergency room services. The emergency room
services fall within the Emergency Care benefit category. The enrollee has been charged the maximum
allowable copay under Medicare rules, which is less than $90 stipulated in the plan contract. This cost sharing
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the
Plan does not have to waive the copayment for Emergency Room Services (G0463) provided August 31, 2019
by the provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 26, 2019 by out of network provider.You asked the Plan to pay forthe mammography services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were provided out-of-network and there was no prior authorization.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 forthe medical services provided on August 26, 2019 by out of network provider.