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

We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe gingival inflammation, full mouth, after oral evaluation (D4346) provided April 26, 221.

You asked the Plan to pay for the dental services. You say that your dental plan says periodontal care. It does not stipulate phases and types of periodontal care. The Plan denied your request. The Plan says this service is not covered under the Plan 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe gingival inflammation, full mouth, after oral evaluation (D4346) provided April 26, 221.
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 is not medically necessary.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 15.

You asked the Plan to pre-approve the dental service. You say that crowns are very expensive. You also say
that you cannot afford this service without coverage. The Plan denied your request. The Plan says crown 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 crown is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown
(D2750) for tooth # 15.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zirabev.

You asked the Plan to pre-approve Zirabev. You say that you would like this drug to be approved for coverage. The Plan denied your request. The Plan says Zirabev is indicated for metastatic renal cell carcinoma (kidney cancer that has spread outside of the kidneys) in combination with Interferon Alfa.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Zirabev. Our reviewer says that Zirabev is not medically reasonable and necessary. Our physician reviewer found Avastin is approved as a subsequent therapy for clear cell carcinoma of the kidney. Our reviewer found that it is not approved in combination or alternating with Pazopanib. Our physician reviewer also found that this is a clinical trial and thus experimental/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 Zirabev have not been met. Therefore, we decided that the Plan does not have to pre-approve Zirabev.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92134) provided on March 25, 2021.

You asked the Plan to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92134). The Plan denied your request. The Plan says the correct copay was applied based on the member's 2021 Evidence of Coverage (EOC).

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 $40 copayment for Outpatient diagnostic tests.

You have been asked to pay a $40 copayment for scanning computerized ophthalmic diagnostic imaging (92134). Scanning computerized ophthalmic diagnostic imaging (92134) falls within the outpatient diagnostic tests 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 scanning computerized ophthalmic diagnostic imaging (92134) provided on March 25, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the present setting where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the outpatient dental services provided out of the country by an out of network provider.

You asked the Plan to reimburse the dental services. You say that you are appreciative of the payment you received but you do not agree with the amount reimbursed. The Plan denied your request. The Plan says the maximum dental benefit amount has been exceeded.

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 maximum yearly allowable benefit of $2,300 for preventative and comprehensive services for dental services.

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.

You have asked the Plan to reimburse you $2,917.50. The health plan contract says that there is a maximum yearly allowable benefit of $2,300 for preventative and comprehensive dental services. The records show that the amount of the benefit previously used was $1,074. Therefore, you are only eligible for $1,226.00 and the benefit is exhausted. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or service has been exhausted. Therefore, we decided that the Plan does not have to reimburse the outpatient dental services provided out of the country by an out of network provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an artificial iris implantation in the left eye.

You asked the Plan to pre-approve insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens (0616T). You say that this procedure is covered by Medicare. The Plan denied your request. The Plan says that medical studies haven't proven that the procedure is helpful for treatment of the enrollee's health problem.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens (0616T). Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found treatment of the patient's aniridia and aphakia with artificial iris implant is medically necessary in this case. There is evidence in the medical literature that the device is safe and effective. Because iris atrophy aniridia is not a widespread phenomenon, there are not robust clinical trials for such a device. Nonetheless, there are numerous smaller trials and investigational studies for this device and other similar devices, that have demonstrated safety and efficacy for treating this disease. The physician's argument that the surgery is superior to available alternatives is valid. Treatment with contact lenses, corneal tattooing, or tinted spectacles are not adequate treatments for the patient's disease. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens (0616T) have been met. Therefore, we decided that the Plan has to pre-approve an artificial iris implantation in the left eye.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor 2 (F2) and Factor 5 (F5) genetic testing.

You asked the Plan to pre-approve the F2 and F5 genetic testing. You say that the requested genetic testing is medically necessary. The Plan denied your request. The Plan says the requested testing is excluded from coverage by Medicare.

The Plan must follow Medicare rules. Medicare rules say that genetic testing for the requested genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients.

We looked at the file and Medicare rules. The records do not show that the enrollee is pregnant. Based on this information, we decided that Medicare rules for coverage of the F2 and F5 genetic testing have not been met.

Therefore, we decided that the Plan does not have to pre-approve Factor 2 (F2) and Factor 5 (F5) genetic testing.
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 is not medically necessary.

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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is replaced in cases of irreparable damage and/or when it has exceeded the reasonable useful lifetime period of five years.

We looked at the file and Medicare rules. The file shows that you received a CPAP device in September of 2016. The device is not yet five years old as of the date of the appeal request and is not irreparably damaged. 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 a replacement continuous positive airway pressure (CPAP) device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 genetic testing services.

You asked the Plan to pre-approve the F5 genetic testing services. You say that the requested genetic testing is medically necessary. The Plan denied your request. The Plan says the requested testing is non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that the requested genetic testing is non-covered, except for in pregnant patients.

We looked at the file and Medicare rules. The enrollee is not pregnant. Based on this information, we decided that Medicare rules for coverage of the F5 genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve F5 genetic testing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 27, 2021.

You asked the Plan to pay for the dental services. You say that you only had your teeth cleaned. You say that you have never used your benefits for cleaning. You also say that you do not understand why dentists have to charge for an exam every time when they can get that information from other dentist with a release. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the comprehensive oral evaluation that you received on June 10, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you feel you need this rehabilitation to allow yourself to become independent. You say that without this, you will not have a good quality of life. You also say that your doctor feels this is absolutely necessary. The Plan denied your request. The Plan says your rehabilitation needs to do not require an intensive team approach. The Plan also says that your needs can safely be met in your current hospital setting.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The reviewer found that while the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. The reviewer also found that here is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, the file does not indicate that you would benefit from an intensive rehabilitation therapy program. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.