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

We decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested admission 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 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the records from the first admission have not been submitted for review. Therefore, it has not been shown that the first discharge was premature or an attempt to circumvent pay per service rules. The records from the second admission indicate that the enrollee was initially discharged in an improved state, with an updated medication regimen. That the enrollee returned, because the enrollee got insufficient relief from the regimen is not an indication that the enrollee was initially prematurely discharged. The records do support that the second admission was medically necessary. Therefore, the enrollee meets criteria for the requested IRF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have been met.Therefore, we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for4 additional surgical extractions (D7210) and unspecified preventive procedure (D1999) provided on June 1, 2020.You asked the Plan to pay forthe dental services. You say that you relied on the provider's office to determine whether the services would be covered. You say that the provider was the one to obtain authorization for the services. You also say that you were never advised that only 2 extractions per yearwould be covered.The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan says that the frequency limit for extractions has been exceeded. The Plan also says that unspecified preventive procedure 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 frequency limit of 2 extractions per calendar year has been exceeded. The record shows that the plan paid already paid for 2 extractions that you received on this date of service. Additionally, the unspecified preventive procedure is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for4 additional surgical extractions (D7210) and unspecified preventive procedure (D1999) provided on June 1, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on
April 20, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee out of network on
April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided from May 24, 2020, to June 23, 2020 by an out of network provider.
You asked the Plan to pay for the skilled nursing facility services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says proper authorization was not obtained.
Medicare rules say that plans can require authorization before receiving services. The requested provider in this case is not a network provider with the Plan. 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 skilled nursing facility services provided from May 24, 2020, to June 23, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided June 5, 2020 to June 11, 2020.
You asked the Plan to pay for the inpatient 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 the inpatient 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 was treated with OxyContin, Oxycodone PRN and IV Morphine PRN for pain control. Suspecting primary lung malignancy. A progress note from June 4, 2020 recommended the enrollee to be discharged with adequate pain medication and set up with outpatient radiation treatment within 1 to 2 days. The enrollee's vital signs and labs were stable.
The enrollee did not require or receive any inpatient diagnostic studies or therapeutic interventions. The enrollee was hemodynamically stable and tolerating oral medications and an oral diet. Therefore, the services rendered were 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided June 5, 2020 to June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options coded as K0861 with power tilt/recline seating system.
You asked the Plan to pre-approve the PWC as requested. You say that it is felt that the requested type of PWC is necessary for this enrollee. The Plan denied your request. The Plan says though the enrollee does meet for the Group 3 PWC, criteria for the model with multiple power options are not met.
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC is only covered when the enrollee has need of certain components are 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 the PWC as requested. Our reviewer says that the requested type of PWC is not considered reasonable and necessary based on the LCD guidelines. Our physician reviewer found the patient is not at high risk for development of a pressure ulcer, does not use intermittent catheterization for bladder management and does not need the power seating system to manage increased tone or spasticity. The patient does not meet the criteria for the power tilt and power recline seating features, and as such, the documentation does not justify coverage for the PWC with multiple power options. 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 PWC as requested have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options coded as K0861 with power tilt/recline seating system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 14, 2020. You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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 June 14, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pa ys for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for the additional routine transportation trips. The Plan denied your request. The Plan says you have used 50 trips and you have 0 remaining trips for the 2020 calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that you have used all 50 of the routine transportation trips for the 2020 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on March 17, 2020.You asked the Planto waive the copayment for an ultrasound. You say that you did not know your policy became effective. The Plan denied your request. The Plan says the correct copayment has been 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 $125 copayment for outpatient diagnostic tests/in-network/radiological diagnostic services. You have been asked to pay $90.34 which is less than your copayment amount of $125 for an ultrasound. An ultrasound falls within the outpatient diagnostic tests/in-network/radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on March 17, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D testing and thyroid stimulating hormone (TSH) testing (84443) provided on May 18, 2020.
You asked the Plan to pay for vitamin D and TSH testing. You say that this is supported by the records. The Plan denied your request. The Plan says these were screening tests.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, vitamin D and TSH testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for vitamin D testing and thyroid stimulating hormone (TSH) testing (84443) provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses you received on March 15, 2019. You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the eyeglasses you received on March 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on June 22, 2020. You asked the Plan to pay for the refraction. You say that you were not told this wouldn't be covered. The Plan denied your request. The Plan says that this is not covered if part of a medical eye exam. 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 obtained during a routine exam. We looked at the file and the Plan's rules. The file indicates the refraction occurred during a medical eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion interspinous spacer (22869).You asked the Plan to pre-approvea Superion interspinous spacer. 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. 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 a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Superion interspinous spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion interspinous spacer (22869).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received from December 31, 2019, to January 15, 2020.You asked the Plan to pay forthe services. You say that you should be reimbursed for these services.The Plan denied your request. The Plan says the receipts are difficult to determine.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted contains receipts that are difficult to read and partially illegible. Without clear receipts and payment documentation, it cannot be determined that Medicare coverage criteria have been met, and whether payment can be made. 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 pay forthe services you received from December 31, 2019, to January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea MyoPro Motion G Orthotic device (L8702).You asked the Plan to pre-approvethe orthotic device. You say that the device is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.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 the orthotic device. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found it is clear that patient will benefit from the device in question. Studiesand medical literature support that the device would be beneficial for the patient.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 orthotic device have been met.Therefore, we decided that the Plan has to pre-approvea MyoPro Motion G Orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you need this for your security.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital stay provided.

You asked the Plan to pay for inpatient hospital stay. You say that the services provided were medically necessary.The Plan denied your request. The Plan says that there was no evidence member's treatment could not have been met at a less restrictive, outpatient level of care.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 hospital stay. Our reviewer says that the inpatient level of care was medically necessary. Our physician reviewer found on June 30, 2020, that the enrollee was not stable for transfer to a lower level of care. Furthermore, based upon a review of the records 
provided the admission of this patient does meet criteria for acute inpatient mental health treatment as although this patient was not shown to be a danger to himself or others he did have perceptual disturbance including auditory, visual hallucinations and delusions. I

t did appear that active treatment was taking place. In addition it appears that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital stay have been met.Therefore, we decided that the Plan has to pay for the inpatient hospital stay provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe admission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that you need SNF care.The Plan denied your request. The Plan says rules for SNF care have not been met.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 admission to a SNF. Our reviewer says that dailyskilled services are not necessary. Our physician reviewer found although there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. Furthermore, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approvethe admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion interspinous distraction device (22870, 22869, C1821).You asked the Plan to pre-approvea Vertiflex Superion interspinous distraction device. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 a Vertiflex Superion interspinous distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion interspinous distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion interspinous distraction device (22870, 22869, C1821).