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

We decided that the Plan does not have to waive the cost-sharing for an X-Ray examination and injection of triamcinolone acetodine (a Medicare Part B prescription drug).

You asked the Plan to waive the cost-sharing for X-Ray and injection. You say that you are appealing these charges. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.

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 $500 deductible for X-Ray and 10% coinsurance for injection. At the time this claim was processed, $30.34 of the $500 deductible had been met. The allowed amount of the X-Ray is $93.26, resulting in a deductible amount of $93.26. The allowed amount of the injection is $1.50, resulting in a coinsurance amount of $0.15. Your total cost-sharing obligation is therefore $93.41.

You have been asked to pay $500 deductible for X-Ray and 10% coinsurance for injection. X-Ray and injection fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Medicare Part B Prescription Drugs" benefit categories. 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 cost-sharing for an X-Ray examination and injection of triamcinolone acetodine (a Medicare Part B prescription drug).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a hand-finger orthosis (HFO).

You asked the Plan to waive the coinsurance for hand-finger orthosis. You say that you feel that the price for this is exorbitant. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 20% coinsurance for hand-finger orthosis. The allowed amount of the claim is $253.25, resulting in a coinsurance obligation of $50.65.

You have been asked to pay 20% coinsurance for hand-finger orthosis. Hand-finger orthosis falls within the Prosthetic Devices and Related 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 coinsurance for a hand-finger orthosis (HFO).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections (96375, 96413, 96415, J2350, J2930) provided by an out of network (OON) provider.

You asked the Plan to pay for OON injections. You say that you believed this was authorized. The Plan denied your request. The Plan says there is not a valid referral 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 had network providers available who could have provided 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 injections (96375, 96413, 96415, J2350, J2930) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 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 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on September 18, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says that there was no authorization, and there is a lack of necessity.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record did show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second annual physical exam received on September 28, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the annual benefit is exhausted.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Plan rules state that the annual physical exam is covered once per year. 

An annual exam was previously received less than a year prior to the date of service on February 26, 2020. Based on this information, we decided that plan rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a second annual physical exam received on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue diabetic test strips.

You asked the Plan to pre-approve OneTouch Ultra Blue test strips. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for these test strips is correct, because you can use test strips from one of the Plan's preferred brands. The Plan also says that they have approved this request through the first 90 days of the new Plan year to help with a transition to a preferred brand.

The Plan must follow Medicare rules. Medicare rules say that the Plan may limit coverage to certain brands of diabetic testing supplies. The Plan contract says that the Plan's preferred brands of diabetic test strips are ACCU-Check or Trividia products. 

We looked at the file and Medicare rules. The requested OneTouch Ultra Blue test strips are not the Plan's preferred brand of test strips. The Plan has approved a 90-day supply of these strips to allow you to transition to a preferred brand. Based on this information, we decided that the Plan's rules for coverage of OneTouch Ultra Blue test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom prosthetic finger (L7499).

You asked the Plan to pre-approve the finger. You say that this is medically necessary. The Plan denied your request. The Plan says this request cannot be approved at this time.

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 finger. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the custom prosthetic finger (L7499) appears to exceed your medical needs per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). The documentation does not reveal that you require this to complete MRADLs or that this finger is necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

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 finger have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom prosthetic finger (L7499).
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 need to regain strength to care for yourself. The Plan denied your request. The Plan says your needs could be met 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 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record documents a need for physical and occupational therapy, but not for an intensive rehabilitation program. Medically necessary services could be provided in a low level of care. There is a not reasonable expectation that you 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth cleaning of heavy deposits (D4355) for the
enrollee.

You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says the x-rays do not show evidence of heavy calculus presence.

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 dental
services 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 dental services. Our reviewer says
that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the
request was made for debridement of the teeth to allow for comprehensive evaluation. The current records do
not include pertinent x-rays that would necessarily show heavy tartar deposits to allow for the service. The
records provided indicate that the enrollee had a general cleaning sometime prior to this request, and a
debridement within the past three years. The plan limits coverage under D4355 to once every three years.
Given the lack of supporting evidence of heavy tartar deposits that would make a comprehensive examination
impossible, and the plan limitations which disallow the service if claimed more frequently than once in a three year
period, there is no necessity for the requested procedure.

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 dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve tooth cleaning of heavy deposits (D4355) for the enrollee.
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 are appealing based on medical necessity. The
Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record
documents a need for physical and occupational therapy, but not for an intensive rehabilitation program.
Medically necessary services could be provided in a lower level of care. There is not a reasonable expectation
that this enrollee 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.
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 you are able to handle the required IRF
therapy. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. While the record documents a need
for physical and occupational therapies, it does not document a need for an intensive rehabilitation program.
Medically necessary services could be provided in a lower level of care. There is not a reasonable expectation
that you 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary immediate denture.

You asked the Plan to pay for the maxillary immediate denture. You say that the enrollee needed this service.
The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, 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
maxillary immediate denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your medical condition is stable. The Plan also says that you do not have any acute medical needs.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described.

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. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy, but not for an intensive rehabilitation program. Our physician reviewer also found that there is a not reasonable expectation that you 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 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 this is medically necessary for the enrollee to regain independence. The Plan denied your request. The Plan says the enrollee's needs could be met 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 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 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. While the record supports that the enrollee needs physical and occupational therapy, she does not need this therapy as part of an intensive rehabilitation program. Medically necessary services could be provided in 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 the member can safely receive their care in a lower level.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is a not reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. There are no complex nursing or rehabilitation needs. Medically necessary services could be provided in a low 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.