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

We decided that the Plan does not have to pre-approve Duloxetine capsules.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee has benefited from this medication and you strongly recommend that she continue.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveDuloxetine capsules.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora drug test provided on August 15, 2019.You asked the Plan to pay forthe drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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-approvethe servicesat issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay fora drug test provided on August 15, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient level ofcare.You asked the Plan to pre-approveacute inpatient level of care. You say that the requested acute inpatient level of care is medically necessary.The Plan denied your request. The Plan says the requested acute inpatient level of care is notmedically necessary and observation level of care is approved.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 acute inpatient level of care. Our reviewer says that the requested acute inpatient level of care is not medically necessary. Our physician reviewer found the enrollee presented to the Emergency Department on 1/22/20 with productive cough and with pain in her back and left hip. Vital signs were notable for hypertension. Heart rate,respiratory rate, temperature, and oxygen saturation were normal. Laboratory studies were notable for leukocytosis. A chest X-ray revealed opacity at the left base, as well as pulmonary vascular congestion. Testing for respiratory syncytial virus (RSV) was positive. Her past medical history is notable for coronary artery disease, chronic kidney disease, shingles, thyroid disease, urinary tract infection, and hypertension. The enrollee was initially treated in the Emergency Department with antibiotics (ceftriaxone and azithromycin) for sepsis. On 1/23/20, the enrollee reported feeling "rotten". Her problem list at that time included back pain, RSV infection, chronic hyponatremia, and hypertension. She was not requiring oxygen. Antibiotics were not being administered. Lidocaine patch and naproxen were ordered for pain. Flonase was ordered for a runny nose. Repeat labs were ordered. The enrollee was evaluated by physical therapy on 1/24/20. She was likely at her baseline mobility. The documentation in the case file does not support that acute inpatient level of care is medically reasonable and necessary for the enrollee in this case. The enrollee is not receiving services that could not be provided at a 
lower level of 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 acute inpatient level of care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient level of care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from May 31, 2019 through June 5, 2019.You asked the Plan to pay forinpatient mental health care. You say that the stay was 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 inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient mental health care. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of May 31, 2019 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, being compliant with treatment while having auditory or visual hallucinations and was not showing any aggressive behaviors.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 mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from May 31, 2019 through June 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond fixed partial denture (code D6930) provided on August 27, 2019.
You asked the Plan to pay for the re-cement or re-bond fixed partial denture. You say that you were never told that this service would not be covered under your plan. The Plan denied your request. The Plan says your plan does not cover this procedure.
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 the re-cement or re-bond fixed partial denture (code D6930) provided on August 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on March 21, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you went for a screening. You say that this should be considered preventive not a procedure.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 $250 copayment for each in-network, Medicare-covered ambulatory surgical center service.You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The colonoscopy with biopsy is considered a surgical procedure. 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 colonoscopy with biopsy provided on March 21, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Inspire system (CPT 0466T and CPT 64568).You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says under Medicare rules, this request is not covered.The Plan must follow Medicare rules. Medicare rules say that CPT 0466T is not a covered code.The request is coded with CPT 0466T and CPT 64568. As CPT 0466T is specifically not covered, the related other code also cannot be covered. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Inspire system (CPT 0466T and CPT 64568).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services provided on May 22, 2019.You asked the Plan to pay forthe physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 physician's services. We found no exception that would requirethe Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forphysician's services provided on May 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaboratory services to be provided by the out of network provider. You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 pre-approved care.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-approvelaboratory services to be provided by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you should not have to pay for the ambulance services because you were not transported by the ambulance. You say the responders came and bandaged you but did not provide any transportation. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOzempic tablets.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generallydoes 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-approveOzempic tablets.Benefits for self-administered drugsmay 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 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 underwent spinal decompression surgery 9 months ago. The enrollee's physician is recommending IRF due to increased weakness in bilateral legs with weekly falls at home even while using a walker. Hemodynamics appear stable, as per medical records. There is no documented sepsis or signs of infection. History is notable for depression, post-traumatic stress disorder (PTSD), and implant of a spinal cord stimulator (SCS) for chronic back pains. 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 pain medication and other medication management, skin care, and daily therapy can be provided at a lower level of care. In this case, the member is needing some assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will definitely allow for measurable gains to be attained within a reasonable and 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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation (PMR) physician three times per week or acute rehab nursing care. While they may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial intraoral x-ray (D0220), the additional intraoral xray
(D0230), and the topical application of fluoride (D1208) provided on September 18, 2019.
You asked the Plan to pay for the intraoral x-rays, and the fluoride treatment. You say that the provider is
participating with the Plan. You say that you found the provider on the Plan website. The Plan denied your
request. The Plan says intraoral x-rays are not listed as a covered service. The Plan also says that fluoride
treatment 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 dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial
intraoral x-ray (D0220), the additional intraoral x-ray (D0230), and the topical application of fluoride (D1208)
provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 17, 2019 to November 5, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 17, 2019 to November 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips (A4253), lancets (A4259), calibrator solution (A4256), and a battery (A4235) provided from July 23, 2019 to October 11, 2019.You asked the Plan to pay fortest strips, lancets, calibrator solution, and a battery. You say that these items should be covered.The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier.Therefore, we decided that the Plan does not have to pay fortest strips (A4253), lancets (A4259), calibrator solution (A4256), and a battery (A4235) provided from July 23, 2019 to October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain or ceramic crown on tooth #2.You asked the Plan to pre-approvethe crown. You say that you need a crown to stop the pain on a tooth that was sawed in half that did not have to be.  You also say that you should still have dentalmoney for a crown.The Plan denied your request. The Plan says your benefit has been exhausted and is not eligible for a dental crown at this time.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 replacement of removable and fixed prostheses were inserted at least 60 months prior to the replacement. The record shows that you received a retainer crown on June 28, 2019 and your removable and fixed prostheses replacement benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea porcelain or ceramic crown on tooth #2.