Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee suffered a fall at home. The hospital course included pain management, and IV steroids for acute encephalopathy (COVID-19 positive). The enrollee is now hemodynamically stable, and non-toxic. He remains minimal/moderate assist overall, for mobility, activities of daily living, and transfers. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate/minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospice long-term care services provided from October 1,
2019 to October 31, 2019.
You asked the Plan to pay for long-term care services. You say that you were told that you must bill the Plan
for these room and board charges. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because the billed code is not valid for Medicare purposes and is not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare
purposes and is not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of long-term care services have not been met. Therefore, we decided that the Plan does not have to
pay for hospice long-term care services provided from October 1, 2019 to October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on February 14, 2020 by an out of network (OON) provider.You asked the Plan to pay for hospital discharge day management services. You say that you ask that you consider payment of your services based on the authorization number provided.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 items/services at issue in this appeal. 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 hospital discharge day management services (99239) provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that thePlan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visit and follow-up. You say that this provider performed surgery on you in 2017, and you want to see them because your tumor has reoccurred.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network neurosurgeon.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 andcare that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
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 the enrollee was admitted to the acute care hospital on 7/13/20 with a peritoneal abscess following laparoscopic hiatal hernia repair, and reduction of a gastric volvulus. The abscess was drained percutaneously. IV antibiotics were discontinued on 7/17/20. The enrollee is receiving IV Fluconazole, as well as TPN. The enrollee is taking full liquids and protein boost. As of 7/20/20, the enrollee had mild episodic nausea, but no vomiting. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 pay for removal of impacted tooth (D7220) provided November 13, 2019.You asked the Plan to pay for the dental services. You say that you was not asked if you wanted your crown and caps removed or changed nor were you informed regarding the cost or if this was something that needed to be done.The Plan denied your request. The Plan says this claim was processed correctly per the plan benefits.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 50% coinsurance of the covered charges for endodontic periodontic and oral surgery dental services listed. for Dental services. You have been asked to pay $102 for the dental services. The services fall within the dental 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 pay for removal of impacted tooth (D7220) provided November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens, >= 1.66 p/>=1.80 g (V2783) progressive lens (V2781) UV Lens (V2755 and anti-reflective coating (V2750) purchased February 26, 2020.You asked the Plan to pay for the vision services. You say that yow were aware that certain parts of the glasses would not be covered. You did not realize there was so much extra's that would not be covered.The Plandenied your request. The Plan says these services are not covered under the plan benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when allowance covers standard contact lenses, eyeglasses, single vision or lined multi-focal lens and frame. We looked at the file and the Plan's rules. Enhancements including but not limited to the following are NOT covered through the allowance but may be purchased by the member at an additional cost: Optional cosmetic processes; Anti-reflective, mirror, color or scratch coating; Blended, cosmetic, laminated, oversize, UV protected or polycarbonate lenses; Photochromic lenses, tinted lenses except Pink #1 and Pink #2.; Progressive multifocal lenses; Certain limitations on low vision care; A frame that costs more than Plan allowance. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for lens, >= 1.66 p/>=1.80 g (V2783) progressive lens (V2781) UV Lens (V2755 and anti-reflective coating (V2750) purchased February 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the SNF admission. You say that it is felt that daily therapies would be beneficial to allow the enrollee to return to functional baseline.The Plan denied your request. The Plan says daily skilled services are not required in this case.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has been recently hospitalized due to a hypoglycemic episode and respiratory failure for which he required a short time on a ventilator and was discharged to a nursing home. He presented to ER 7/13/2020 from the nursing home after a fall with head injury with loss of consciousness. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not have complex wound care or other ongoing SN SNF level needs. His functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on February 10, 2020.
You asked the Plan to pay for the bitewing x-rays. You say that you called to confirm coverage. You say that
the book does not say what type of x-ray is covered. The Plan denied your request. The Plan says the service is
not a covered benefit.
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
bitewing x-rays provided on February 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99285) provided January 17, 2020. You asked the Plan to waive the copayment for the Emergency Room Visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied. 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care 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 an Emergency Room Visit (99285) provided January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical each additional x-ray (D0230) provided March 2, 2020.
You asked the Plan to pay for the dental x-rays. You say that you tried to take preemptive measures, but still ended up with inadequate information from the office staff that now has left you with a bill you do not feel should be your responsibility. The Plan denied your request. The Plan says this service exceeds the benefit maximum.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The records show that you received 2 sets of x-rays. The plan has approved payment for the first set of x-rays. 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 intraoral-periapical each additional x-ray (D0230) provided March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal evaluation provided on March 13, 2020.
You asked the Plan to pay for the periodontal evaluation. You say that you had to switch to a different provider. You say that you didn't request this work, it is required as a new patient. The Plan denied your request. The Plan says one periodontal exam or comprehensive oral evaluation is allowed every three years.
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 Plan also has a maximum benefit of one periodontal exam or comprehensive oral evaluation every three years. The Plan paid for an oral evaluation on April 16, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodontal evaluation provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services provided March 11, 2020. You asked the Plan to pay for the refraction services. You say that your eye exam was routine. You received no special treatments. You were diagnosed with cataracts and referred to a specialist for an exam before moving forward with cataract surgery on both eyes. The Plan denied your request. The Plan says this claim processed correctly per the plan benefits. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when completed as a part of a routine annual eye exam. We looked at the file and the Plan's rules. the plan has confirmed that this service was a medical examination and evaluation. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services provided March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOndansetron HCL.You asked the Plan to pre-approveOndansetron HCL. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Ondansetron HCL is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveOndansetron HCL.Benefits for Ondansetron HCLmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prosthodontics on teeth 8, 9 (D6245) endodontic therapy on tooth 10 (D3310) canal preparation on tooth 10 (D3950) and retainer crown on teeth 7, 10 (D6740) provided April 15, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing denial of the claim and request reconsideration for payment and the records provided should support the necessity of the services.The Plan denied your request. The Plan says the services are 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. Services not listed under the Description of Benefits is not covered by the plan.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 prosthodontics on teeth 8, 9 (D6245) endodontic therapy on tooth 10 (D3310) canal preparation on tooth 10 (D3950) and retainer crown on teeth 7, 10 (D6740) provided April 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam services (V2020) provided January 30, 2020.
You asked the Plan to pay for the vision services. You say that once the exam was over you were told you had
to pay $90 for the exam which you were surprised because the plan and the provider said they take your
insurance. The Plan denied your request. The Plan says enrollee's must receive their vision services from an innetwork
provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when provided by an in-network provider.
We looked at the file and the Plan's rules. Vision services must be rendered by a participating provider. Based
on this information, we decided that the Plan's rules for coverage of the vision services have not been met.
Therefore, we decided that the Plan does not have to pay for eye exam services (V2020) provided January 30,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), electrical stimulation (G0283), therapeutic exercises (97110), electric stimulation therapy (97014), and the manual therapy (97140) provided on February 3, 2020 and February 14, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203), electrical stimulation (G0283), therapeutic exercises (97110), electric stimulation therapy (97014), and the manual therapy (97140) provided on
February 3, 2020 and February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent 150mg/mL injection pens. You asked the Plan to pre-approve the Praluent pens. You say that the enrollee is at high risk for cardiovascular events due to history and needs this medication. The Plan denied your request. The Plan says this drug is for self-injection and cannot be covered by Medicare Part B. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent 150mg/mL injection pens.