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

We decided that the Plan does not have to pay for laboratory testing provided on November 18, 2020.
You asked the Plan to pay for lab tests. You say that you performed all the tests ordered by the referring physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Without a physician order, it cannot be determined whether this testing was ordered for Medicare-covered purposes. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for NSTEMI, heart catheterization and placement of stent. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 30, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that prior 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 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 domiciliary or rest home visit provided on October 30, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M).

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that CxBladder Detect is not a covered service. 

We looked at the file and Medicare rules. The genetic testing performed is not a covered service. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from March 7, 2021, forward.
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, you required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of March 6, 2021, you did not require any skilled nursing or rehab services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of March 6, 2021. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved, however your function had plateaued by March 6, 2021, and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of March 6, 2021, you required custodial services. The denial for further inpatient skilled care is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from March 7, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the spinal spacer placement.. You say that the procedure is medically
necessary. The Plan denied your request. The Plan says this service is experimental and is not covered.
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 spinal spacer placement. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the requested Vertiflex interspinous spacer is considered investigational and is
not the standard of care for the enrollee's condition. More research is needed to show safety and efficacy of the
device.
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 spinal spacer placement. have not been met. Therefore, we decided that the
Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation visits provided
from October 2, 2020, to October 30, 2020.
You asked the Plan to waive the copayments for the cardiac rehabilitation visits. You say that your
rehabilitation bill was not paid by the Plan. The Plan denied your request. The Plan says you have been asked
to pay 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 $20
copayment for each in-network Medicare-covered cardiac rehabilitative visit.
You have been asked to pay $20 copayment for each of the cardiac rehabilitation visits. ($20 x 13 visits =
$260). The cardiac rehabilitation visits fall within the "Outpatient Rehabilitation 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 copayments for the cardiac rehabilitation visits provided from October 2,
2020, to October 30, 2020.
Your complaint about leaving the Plan is not a valid appeal for medical coverage. This part of your complaint
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), and the bitewing x-rays (D0274) provided on September 17, 2020.
You asked the Plan to pay for the dental services. You say that this was your annual dental cleaning. You also say that the services should be covered. The Plan denied your request. The Plan says there is an allowance of $750 every year for covered dental services. The Plan says that the allowance has been exceeded. The Plan also says that you are responsible for any amount above the dental coverage limit.
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 annual $750 allowance has been exceeded. The record shows that the Plan paid $750 towards a crown that you received on July 22, 2020, thus exhausting the allowance. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), and the bitewing x-rays (D0274) provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
November 19, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this oral
exam should be covered. The Plan denied your request. The Plan says this service exceeds the frequency
limitation.
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, oral examinations are limited to two
per calendar year. The record shows that you received oral exams on February 13, 2020, and August 31, 2020,
and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan does not have to
pay for the problem focused limited oral evaluation provided on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a CardioMEMS device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that research studies have found a lack of evidence that routine use of this would improve the outcome for the enrollee's condition.

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 requested services are not considered medically reasonable and necessary in this case. The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 

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-approve the implantation of a CardioMEMS device for the enrollee.
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-approve the LTACH services. You say that you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member's ongoing needs may be met at a lower level of care.
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 there are no services at the LTACH that the member requires that are not already available and covered at the current location. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray exam of the chest (71046) provided on September 28, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $110 copayment for basic radiological services provided at an outpatient hospital. You have been asked to pay $75.81 for the chest x-ray provided at an outpatient hospital. This is the Plan allowed amount which is less than the applicable copayment for this service. 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 x-ray exam of the chest (71046) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified dental service (D2325) provided on August 26, 2020.
You asked the Plan to pay for the unspecified preventive service (D2325). You say that you were unaware that you had dental coverage during Covid-19. You say that you were not going to a new dentist. You say that you have not been working since the pandemic and do not have $1,000. You also say that you feel the services should be covered due to a re-existing condition that has caused you to stop working. The Plan denied your request. The Plan says the unspecified dental service is not listed as a covered service.
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. There is insufficient information about the services described by CPT code D2325. As such, we are not able to determine if this code is describing a potentially covered service. Therefore, we decided that the Plan does not have to pay for the unspecified dental service (D2325) provided on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy procedure you had on October 29, 2020.
You asked the Plan to waive the copayment for the endoscopy procedure. You say that you do not believe you should have to pay for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for outpatient surgical services. You have been asked to pay a $250 copayment for the endoscopy procedure. The endoscopy procedure falls within the outpatient surgical 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 endoscopy procedure you had on October 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Eylea. Our reviewer says that the medication is necessary. Our physician reviewer found the documentation does not support that Avastin (Bevacizumab) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
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-approve the LTACH services. You say that you would like reconsideration because LTACH admission is medically necessary. The Plan denied your request. The Plan says the member's ongoing needs may be met at a lower level of care.
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 as LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.