Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 4/3/20 for evaluation of cough, chest discomfort and fevers. The member was intubated from 4/4/2020 - 4/14/2020 and has a diagnosis of pneumonia and toxic encephalopathy. The medications include Famotidine and Duloxetine. Now, the records indicate the member is non-toxic and oxygen status is improving/stable. The member has poor endurance, and is minimal assist for functional transfers, and gait using a walker. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing medication management, skin and O2 care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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 waive the benefit limit exception for eyeglasses.
You asked the Plan to waive the benefit limit exception for eyeglasses. You say that although you are medically ready for cataract surgery, it was your decision to forgo surgery in lieu of glasses based upon your doctor's input. The Plan denied your request. The Plan says that your request exceeds the allowable eyewear 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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of routine eyewear have not been met. Specifically, you received eyeglasses previously on June 26, 2018. The benefit allows for only one pair of eyeglasses every two years.
Additionally, the eyeglasses are not a Medicare covered benefit as you have not had a recent cataract surgery. Therefore, we decided that the Plan does not have to waive the benefit limit exception for eyeglasses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forextractions for teeth 3-12, 14, 15, 22-28 (D7140) provided on December 19, 2019.You asked the Plan to pay forthe dental services. You say that you do not understand how the benefit is exhausted when you have not used any of your dental benefits.The Plan denied your request. The Plan says this service exceeds the benefit maximum.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 records show that the plan $98 for date of service October 14, 2019 $1015 and $887 for date of service December 4, 2019. Therefore the benefit has been exhausted.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 forextractions for teeth 3-12, 14, 15, 22-28 (D7140) provided on December 19, 2019
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee on June 13, 2019 by an out-of-network provider.
You asked the Plan to pay for acute inpatient hospital care. You say that the services are medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 the services provided to the enrollee on June 13, 2019 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the outpatient knee surgery provided on September 27, 2019.
You asked the Plan to waive the charges for the outpatient knee surgery. You say that you do not understand why you are being asked to pay the $248.15 and no one at the plan has been able to explain it. If you are required to pay this amount, you do not know why it is listed as Outpatient Pharmacy Regular on the EOB. The Plan denied your request. The Plan says you have been asked to pay 10% of the total allowed charge for this procedure.
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 10% coinsurance for outpatient surgery in a hospital facility. You have been asked to pay 10% coinsurance for the outpatient knee surgery. The outpatient knee surgery falls within the outpatient surgery in a hospital facility benefit category. Please note that the procedure description for each line on your Explanation of Benefits is listed below the line. The $248.15 charge is listed on the line item labeled, Outpatient Surgery Regular. 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 charges for the outpatient knee surgery provided on September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown-porcelain fused to predominantly base metal (D2751 x 2) for tooth number 21 and 28.You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the teeth do not appear to have significant breakdown. The documentation provided does not demonstrate that the requested crowns are medically necessary.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 crowns when 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 porcelain crowns. Our reviewer says that the enrollee does not meet criteria for coverage of the requested crowns. Our physician reviewer found that the documentation provided does not support the need for porcelain crowns as there was no indication of significant coronal breakdown.We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met.Therefore, we decided that the Plan does not have to pre-approve a crown-porcelain fused to predominantly base metal (D2751 x 2) for tooth number 21 and 28.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not authorize to be transported by ambulance. You say that you were informed the ambulance would be covered by the hospital. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each separate Medicare-covered ambulance service. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 ambulance transport provided on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
You asked the Plan to pre-approve a total electric hospital bed. The Plan denied your request. The Plan says the requested bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLidocaine patches for the enrollee.You asked the Plan to pre-approveLidocaine patches. You say that the enrollee suffers from chronic low back pain.The Plan denied your request. The Plan says Lidocaine patches to be administered at home is not covered under the Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveLidocaine patches for the enrollee.Benefits for Lidocaine patchesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature(E2300) for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. The Plan denied your request. The Plan says that this is not covered.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI. Our reviewer says that an MRI of the lumbar spine is not medically reasonable and necessary. Our physician reviewer found that the enrollee was diagnosed with lumbar facet arthropathy, lumbar spondylosis, and chronic lumbosacral pain. MRI lumbar spine from 2015 showed transitional lumbosacral junction with mild L5-S1 degenerative disc and facet disease, but no disc extrusion, central stenosis, or neural foraminal compromise. A recent physical examination from February 3, 2020, showed normal gait, positive facet tenderness to the lumbar area, painful lumbar extension, and normal reflexes, sensation, and strength testing. Repeat lumbar MRI was requested due to the lumbar pain being refractory to conservative and ablation therapy. However, no objective evidence was documented of a progression or change to suggest repeat MRI would reveal any different findings. No evidence of radiculopathy or another red flag diagnosis to justify MRI at this time was provided in the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested admission to a SNF.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with chronic obstructive pulmonary disease (COPD) and left ventricle dysfunction, admitted with a one-week history of shortness of breath. He has chronic cough and uses inhalers. A chest x-ray dated 4/7/2020 was non-acute. The member has no skin breakdown and responded well to medical management and care. He is nowafebrile and non-toxic. Supervision-to-contact guard assist (CGA) is needed for care, and basic activities of daily living. The enrollee is now mostly CGA-to-supervised for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable and SNF is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the addition to lower extremity to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these services. You say that this is medically necessary.The Plan denied your request. The Plan says that there are available in-network providers who can perform the requested service.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. 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 the addition to lower extremity to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).You asked the Plan to pre-approvethese services. You say that your condition will worsen without the CGM.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 therapeutic CGM 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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have type II diabetes and use once-daily insulin with poor glucose control. There is no record that you are insulin-treated with multiple daily injections (three or more) of insulin or are using a Medicare-covered continuous subcutaneous insulin infusion pump. The request does not meet the criteria for coverage of a therapeutic CGM and the services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for four (4) additional intraoral -periapical each additional radiographic image (D0230 x 4) provided on November 7, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you are appealing for reconsideration of the denied charges.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.We reviewed your records and they show that you saw the dentist and received an examination and x-rays. The record sent by your provider indicates that five sets of intraoral x-rays were performed at your visit. However, your dental benefit provides coverage for one set of intraoral x-rays per calendar year. It also indicates that you are responsible for understanding your dental coverage, including its limitations and exclusions. Under Medicare guidelines, your request is not a covered benefit because your records show that you had five sets of intraoral x-rays and one set has already been approved for payment by the Plan. We are unable to approve your request for payment for four additional intraoral x-rays.Therefore, we decided that the Plan does not have to pay forfour (4) additional intraoral -periapical each additional radiographic image (D0230 x 4) provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your previous insurances have provided coverage for the requested foot orthotics. You say that the combination of high foot arches, a serious skiing accident, and a back injury has meant that the orthotics are a life saver for you. Without them, you say that you experience pain in your ankles, feet, knees and back. You live an active lifestyle and you depend on the orthotics rather than on drugs or medicines which you stated may not help or may be addicting. You say that your legs are a little bit uneven and even though you do not use a leg brace, you would like the Plan to reconsider providing coverage. You say that the requested orthotics help you live daily without discomfort and work well. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtandi capsules for the enrollee.
You asked the Plan to pre-approve Xtandi. The Plan denied your request. The Plan says Xtandi to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xtandi capsules for the enrollee.
Benefits for Xtandi may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.