Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and an ultrasound provided on March 30, 2021.
You asked the Plan to waive the copayments for a specialist visit and an ultrasound. You say that you are unhappy with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $45 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $125 copayment for ultrasounds. You had a specialist visit on March 30, 2021. Therefore, you are responsible to pay the $45 copayment.
You received an ultrasound provided on March 30, 2021. Therefore, you are responsible to pay the $125 copayment. The total amount you owe is: $170. You have been asked to pay the total copayment amount of $170 for a specialist visit and an ultrasound. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a specialist visit and an ultrasound provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the crown provided on May 20, 2020 and root canal provided on July 9, 2020.

You asked the Plan to fully pay for the crown and root canal. You say that you had work on a temporary crown, a root canal on the same crown and another visit to have a crown put in. You say that the job was left incomplete and the money you had to pay in advance should be returned. The Plan denied your request. The Plan says the claims processed correctly.

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 is only obligated to pay 50% of the cost for the crown and root canal. Therefore, we decided that the Plan does not have to fully pay for the crown provided on May 20, 2020 and root canal provided on July 9, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on August 7, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was determined to be reasonable and necessary for the management of the enrollee's condition. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the records do not show that this testing meets the Medicare coverage criteria.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that their decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on August 7, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that the requested service is medically necessary. The Plan denied your request. The Plan says guided tissue regeneration 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 guided tissue regeneration is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) for tooth # 3.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic services rendered on February 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. We looked at the file and Medicare rules. The services at issue were performed in the hospital outpatient setting. Payment for these services is included in the OPPS payment to the hospital. Therefore, we decided that the Plan does not have to pay for the diagnostic services rendered on February 24, 2021.
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 believe LTAC is the most appropriate level of care based on the enrollee's current condition and needs. The Plan denied your request. The Plan says the acute care hospital can provide acute care services until the enrollee's condition allows transfer to an alternate 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 the patient appears to be more stable but requires additional short-term acute care services which can be safely completed at the current facility until long-term level of care is determined. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary at this time as there would be no significant clinical advantage to transfer at this time. Transfer may be considered when treatment has completed and an appropriate lower level of care with ventilator support is chosen. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical services provided on March 18, 2021.
You asked the Plan to waive the coinsurance for surgical services provided. You say that you were told by customer services via the phone that this service would be covered. You asked that this amount be removed from your account balance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay 20% coinsurance for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The record shows that the Plan has covered your surgery; however, your coverage includes a cost sharing amount for which you are responsible. You have been asked to pay $935.19 ($4,675.96 X 20% = $935.19) for surgical services. Surgical services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 coinsurance for surgical services provided on March 18, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nexletol tablet, 180 mg.
You asked the Plan to pre-approve Nexletol. You say that the enrollee has tried and failed other medications. You also say that the enrollee has tried samples of Nexletol and has not had issues. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 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 Nexletol tablet, 180 mg.
Benefits for Nexletol may be available under Medicare Part D. Contact the 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 for the enrollee.

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 this member does not have complex medical or intensive rehabilitation needs requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive inpatient hospital environment.

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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for bradycardia and complete heart block and has a pacemaker paced. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 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 the service is medically necessary. The Plan denied your request. The Plan says the service 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 the enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being obtained at the enrollee's current level of care and they do not require any additional
services. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 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 these services are medically necessary. The Plan denied your request. The Plan says that your therapy can be received at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 have a history of left below the knee amputation in December 2018 and right below the knee amputation in July 2021. You have been discharged home. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 7, 2021.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says Medicare does not cover office visits rendered by a chiropractor.
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 service at issue is not manual manipulation of the spine. Office visits, when provided by a chiropractor, are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).

You asked the Plan to pre-approve Vertiflex procedure. You say that the enrollee has failed conservative approaches to treatment and this treatment is considered safe and effective. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is considered unproven and 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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show its safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a prefabricated post and core in addition to crown (D2954) provided on January 19, 2021.

You asked the Plan to pay for a crown, and a prefabricated post and core in addition to crown. You say that the Plan has paid for these services before and they are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown (D2740), and a prefabricated post and core in addition to crown (D2954) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas machine along with subcutaneous vitamin injections services provided from August 13, 2020 to September 9, 2020.

You asked the Plan to pay for Sanexas machine along with subcutaneous vitamin injections services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for Sanexas machine along with subcutaneous vitamin injections services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has peripheral neuropathy. The requested service is not approved by the Food and Drug Administration as safe and effective for the enrollee's condition. This means the elements of the coverage rule are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sanexas machine along with subcutaneous vitamin injections services have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas machine along with subcutaneous vitamin injections services provided from August 13, 2020 to September 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy in your home (G0151).

You asked the Plan to pre-approve the home health services. You say that you would like to continue physical therapy at home. You say that you are uncomfortable about your discharge. You also say that you had multiple falls even in the last 2 weeks. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer says that the requested continuation of physical therapy in your home is not medically necessary. Our physician reviewer found the documentation does not indicate that you require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The documentation indicates that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that you were treated with physical therapy and your function has improved. The reviewer also found that you no longer require the services of a skilled physical therapist. Therefore, the reviewer found that the requested home health services are not medically necessary. 

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 home health services have not been met. Specifically, the file indicates that your condition has improved, and the services are no longer medically necessary. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy in your home (G0151).