Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe outpatient hospital services provided from August 12, 2019 to August 14, 2019.You asked the Plan to pay forthe outpatient hospital services. You say that this procedure was medically necessary.The Plan denied your request. The Plan says that this is not a covered service.Medicare generally does not cover dental services as defined above. However, Medicare does cover services which are reasonable and necessary to diagnose or treat an illness/injury. 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 the removal of an impacted tooth. Our reviewer says that the services at issue are considered medically necessary to treat a medical condition and should not be considered a primarily dental service. Our reviewer found that the enrollee has a medical history including heart disease, sleep apnea, and prior facial trauma whichrequired surgery. He presented in 2019 with facial swelling that had started approximately one month prior. A local incision and drainage (I&D) was performed on 8/6/19. A CT scan of the enrollee's face demonstrated a significant fluid collection in the right masticator space along the lateral right mandibular ramus and body, extending up to the infratemporal space around the right zygomatic arch. On 8/14/19, the enrollee underwent incision and drainage of an abscess in the masticator space, incision and drainage of an abscess in the infratemporal space, and extraction of impacted tooth #32, as the oral surgeon determined that tooth #32 with retained hardware within the right maxilla resulted in the development of recurrent abscesses. The extraction of tooth #32 was not primarily a dental service as it was not performed simply as treatment or care of the tooth or supporting structures. The enrollee's underlying medical condition of recurrent abscesses could not have been adequately treated without removal of this tooth. This was medically reasonable and necessary treatment for the enrollee's medical condition. 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 removal of an impacted tooth have been met.Therefore, we decided that the Plan has to pay forthe outpatient hospital servicesprovided from August 12, 2019 to August 14, 2019.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. 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 is currently undergoing treatment at an acute care hospital (ACH) having initially been admitted with sepsis and new lung lesions. The enrollee underwent a biopsy which was complicated by a hemothorax. The enrollee is not currently intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe ZIO XT Patch to be provided by an out of network provider.You asked the Plan to pre-approvethe out-of-network cardiac monitoring services. You say that you need cardiac monitoring now to get on the right medication.The Plan denied your request. The Plan says the services are available with a participating 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 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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network cardiac monitoring services. Our physician reviewer found the enrollee had transient atrial fibrillation after lung surgery and now has intermittent palpitations several times per week concerning for possible recurrent atrial fibrillation.  In this circumstance in-network off-line monitoring devices such as Holter monitoring or 30-day event monitors should be both safe and effective in assessing forrecurrent atrial fibrillation. The documentation does not support that these devices have been tried and failed or thatthe enrollee would not be able to negotiate wearing these devices. The records do not support the medical necessity for out-of-network Zio Patch monitoring.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 out-of-network cardiac monitoring services have not been met. 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 the out-of-network cardiac monitoring services.Therefore, we decided that the Plan does not have to pre-approvethe ZIO XT Patch to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee would meet criteria for a slower paced rehab plan of care, over a longer
period of time.
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 that you will not be able to endure an IRF stay and you are getting medically stable
for his pneumonia. You are more appropriate for an SNF rehab with low intensity.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased May 3, 2019.You asked the Plan to pay forthe hearing aids. You say that you did acquire a pair of audible hearing aids in 2017 which proved unsatisfactory and were returned in 2019.The Plan denied your request. The Plan says the maximum benefit has been exhausted.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only $500 allowance for hearing aids every 3 years. The records show that hearing aids were received on March 8, 2017. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased May 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer.You asked the Plan to pre-approvethese 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. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain radiating to the right hip and left lower extremity to the ankle. She has severe spinal stenosis. The Superion spacer is considered experimental/investigational and not medically necessary forthis enrollee based on the failure to meet FDA indications for this procedure and the presence of contraindications.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 Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora high frequency chest wall oscillation device (HFCWOD) and accessories.You asked the Plan to pay fora HFCWOD. You say that the item is medically necessary.The Plandenied your request. The Plan says medical necessity criteria have not been met.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 a HFCWOD. Our reviewer says that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. Our physician reviewer found the enrollee does not have diagnoses of cystic fibrosis, post-polio, acid maltase deficiency, anterior horn cell diseases, multiple sclerosis, quadriplegia, hereditary muscular dystrophy, myotonic disorders, other myopathies, or paralysis of the diaphragm. There is no documentation that the enrollee's diagnosis of bronchiectasis has been confirmed by CT scan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met.Therefore, we decided that the Plan does not have to pay fora high frequency chest wall oscillation device (HFCWOD) and accessories
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the specialist services provided on October 16, 2019 and October 30, 2019.You asked the Plan to reduce the coinsurance forthe specialist services. You say that you were not aware that your dermatologist was not in-network.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% coinsurance for out-of-network physician specialist services (including surgery second opinion and telehealth or urgently needed services). You have been asked to pay a total of $624.74 for the specialist services. The specialist services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows this provider is out-of-network. See chart below. 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 reduce the coinsurance forthe specialist services provided on October 16, 2019 and October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.You asked the Plan to pre-approvethe skilled nursing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the home health services are not medically necessary.The Plan must follow Medicare rules. The rules saythat home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 skilled nursing services. Our reviewer says that the submitted records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you. Our physician reviewer found the documentation also does not reveal that you are confined to the home .We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysneeds can 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 22, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.You asked the Plan to pre-approve the CardioMEMs device. You say that the current standard of care is not effective and the device will help to monitor the member's condition. The Plan denied your request. The Plan says this device is experimental and investigational.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 CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMs device is uncertain at this time and not recommended in current guidelines for the treatment of heart failure. The device should still be considered experimental or investigational.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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepregabalin for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approvepregabalin for the enrollee. Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysyou do not have any acute or new medical conditions, and you are stable.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. Your pain is controlled, your anemia is not severe and not unusual after surgery. Your vital signs are stable. There are no signs of infection. You may benefit and participate in additional therapy of PT and OT but you are at a functional level that does not require this on an intensive rehabilitation facility therapy program level 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-rays (D0330), the limited oral evaluation (D0140), the moderate sedation (D9239), or the incisional biopsy of oral tissue (D7286) provided on October 17, 2019.You asked the Plan to pay forthe panoramic x-rays (D0330), the limited oral evaluation (D0140), the moderate sedation (D9239), and the incisional biopsy of oral tissue (D7286). You say that you cannot afford these medical costs and find them to be unreasonable. The Plan denied your request. The Plan says the services are not covered benefits.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 panoramic x-rays (D0330), the limited oral evaluation (D0140), the moderate sedation (D9239), and the incisional biopsy of oral tissue (D7286) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe panoramic x-rays (D0330), the limited oral evaluation (D0140), the moderate sedation (D9239), or the incisional biopsy of oral tissue (D7286) provided on October 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on September 23, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says you were charged this cost sharing 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 $200 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $200 for these services. 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 forthe ambulance services provided on September 23, 2019.