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

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the brain (70553) and two (2) MRI's of the spine (72156, 72157) provided on January 18, 2021, to January 28, 2021.

You asked the Plan to waive the copayment for MRI's of the brain and spine. You say that your provider ordered a yearly MRI and you have never paid more than one copayment for your yearly MRI no matter how many slides the provider requests. You also say that you do not agree with the three copayments being assessed. The Plan denied your request. The Plan says the copayment you are being charged is correct. The Plan also says that you did not become active with this Plan until January 1, 2021, so there are no claims to compare this date of service with.

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 $160 copayment for each outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $160 copayment for MRI's of the brain and spine. The EOC confirms that $160 is the required copayment for each MRI performed. The records show that you had three (3) MRI's ($160 x 3 = $480). MRI's of the brain and spine fall 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 magnetic resonance imaging (MRI) of the brain (70553) and two (2) MRI's of the spine (72156, 72157) provided on January 18, 2021, to January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 21, 2021 by an out of
network (OON) provider.

You asked the Plan to pay for physician services. You say that you went to see if you could use medical
marijuana for the treatment of early Parkinson's disease. The Plan denied your request. The Plan says prior
authorization was not obtained by the member's primary care physician.

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 physician services
provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with altered mental status due to intracranial hemorrhage. The enrollee has had a prolonged hospital course and is still deemed critically ill with both pulmonary and neurologic deterioration. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until April 9, 2021. This means that more than one
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan
does not have to pay for the services provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and
accessories (E0667).

You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that you need this
specific device. The Plan denied your request. The Plan says you have not had a trial of a standard device.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, no records have been submitted that show that you have
had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, inperson
fitting, training and supervision by a technician who is skilled in and who regularly and successfully
uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic
compression device (E0652) and accessories (E0667).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the wound care at home does not work and you have to be off of your legs. You say that you to keep your legs elevated. You say that the condition cannot be healed without going to a SNF. The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care or daily skilled rehabilitation therapy.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was to complete a course of oral antibiotics. The enrollee was treated for pain and had uncomplicated chronic wound care. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand by assist level with functional mobility, including gait to 200 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ostomy supplies (A4431) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ostomy supplies. You say that you insist on using the products from this provider as they service your needs and you like their products. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve ostomy supplies (A4431) to be 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 psychotherapy services (90837) provided on January 3, 2021, by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 psychotherapy services (90837) provided on January 3, 2021, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.

You asked the Plan to pre-approve the inpatient mental health services. You say that without the inpatient
mental health admission, you would be at risk for harming yourself and at minimum readmission. You say that
you remain a safety risk to yourself due to ongoing mood instability and side effects of medication. The Plan
denied your request. The Plan says the guidelines for coverage have not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 inpatient mental health services. Our reviewer says that the criteria for coverage of inpatient psychiatric services have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on June 18, 2021 with Bipolar Disorder, Current Episode Manic without Psychotic Features, Severe. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee
was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates
in question. The enrollee could have been treated in a lesser restrictive 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 inpatient mental health services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower
denture (D5214).

You asked the Plan to pre-approve dentures. You say that your current dentures are painful and fall off
regularly and need to be replaced. The Plan denied your request. The Plan says dentures can only be covered
once every five years, and your last pair was provided and covered in 2020. The Plan also says they contacted
the provider who gave you your current dentures and found that you have not seen them since shortly after
receiving the dentures in October 2020. This provider is still able and willing to assist you to repair or fix the
issue.

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 can pay for one
denture per jaw every 5 years.

Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
a complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient does require physical and occupational therapy but there is no documented
need for an intensive rehabilitation program.
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. Specifically, medically necessary services can be
obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (99204) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you would like a second opinion as you are still having problems with your eye care. You also say that you would like to see a new provider. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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 records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (99204) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is very complex in the care they need. The Plan denied your request. The Plan says the stay is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with fever and thrombocytopenia, possibly chemotherapy related. The enrollee had previously been hospitalized with altered mental status, dysphasia and fall from middle cerebral artery occlusion. At this time, the enrollee has a persistent leukocytosis from a sacral wound. The enrollee has evidence of metastatic lung disease. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services
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. You say that the enrollee will benefit from rehab that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee does not need an intensive team for care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for sepsis and right leg cellulitis. His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.

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 a complete upper denture (D5110) and partial lower denture (D5214).

You asked the Plan to pre-approve dentures. You say that your last dentures that were made in 2018 were not made correctly. They are cracked and uncomfortable and you need them replaced. The Plan denied your request. The Plan says they previously paid for dentures for you in 2018. Since it has been less than 5 years since you were last provided with Plan-covered dentures for each jaw, new dentures cannot be approved.

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 can cover one denture per jaw every 5 years. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower denture (D5214).