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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for right foot osteomyelitis and had above the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. 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 pre-approve the anemia evaluation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the anemia evaluation. You say that you do not believe the Plan is treating your anemia appropriately and you want to be seen by a non-network provider. The Plan denied your request. The Plan says the provider is out of network

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 care 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-approve the anemia evaluation to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 999 additional routine transportation trips.
You asked the Plan to pre-approve 999 additional routine transportation trips. You say that you need these trips to get to dialysis appointments. The Plan denied your request. The Plan says you have only 5 trips remaining in this benefit.
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 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that this request exceeds the Plan's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 999 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a continuous glucose monitor has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953)
provided October 20, 2020.

You asked the Plan to pay for the bone replacement graft. You say that you were told the service would be
covered. The Plan denied your request. The Plan says the service is not covered under your dental 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 the bone
replacement graft for ridge preservation (D7953) provided October 20, 2020.

Your complaint about potentially receiving misinformation about coverage of the service is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion.

You asked the Plan to pre-approve Vertiflex Superion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve Vertiflex Superion. 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 chronic low back pain. The spacer is experimental. More research is needed to show the safety and efficacy of interspinous spacers. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex Superion have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
You asked the Plan to pre-approve the full mouth debridement. The Plan denied your request. The Plan says this service conflicts with another service provided in the enrollee's history.
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, a full mouth debridement (D4355) cannot be performed the same day as or less than 1 calendar year after an evaluation (D0120, D0150). The record shows that the enrollee received a periodic oral evaluation (D0120) on February 2, 2021, and the enrollee's full mouth debridement (D4355) benefit cannot be provided. Therefore, we decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (MPI).

You asked the Plan to pre-approve myocardial perfusion imaging (MPI). You say that the requested MPI is
medically necessary. The Plan denied your request. The Plan says that the services can be provided by an innetwork
provider.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Medicare says that the plan must pay for emergency and urgently needed
services. This rule applies whether the services are obtained in or out of the plan's network. This rule applies
whether or not there is prior authorization for the services. The rules say that urgently needed services are those
needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan.
Generally, these services are needed while the enrollee is outside of the service area.

In this case, the file shows that the enrollee lives in one state; however, the request is for services to be obtained
by a provider and facility that is in another state. We sent a request to the Plan for clarification in that it is
unclear if the enrollee is currently out of the Plan's service area. That Plan has not responded. We are unable to
determine if the Plan's denial is justified as the file does not contain enough information to determine if the
enrollee meets out of area coverage criteria. We do not know if the enrollee had recent symptoms that led to the
request for the MPI that started prior to leaving the Plan's service area or after. We do not have documentation
to clarify if the enrollee was receiving care and treatment for these symptoms prior to leaving the Plan's service
area. We find that the Plan has not supported their reasoning for denial. Therefore, we decided that the Plan has
to pre-approve myocardial perfusion imaging (MPI).

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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), 2 surgical extractions (D7210), the periapical x-ray (D0220), and the immediate partial upper denture (D5221) provided on January 16, 2020.
You asked the Plan to reimburse you for the dental services. You say that the services should be covered. You say that you have been seeing this dentist for years before you retired and before you had this plan. You also say that you have since stopped using him as you understand he is not in network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that you receive out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation and surgical extractions are listed as covered services, dental services that you receive out of network are not covered. Additionally, the periapical x-ray and immediate upper denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), 2 surgical extractions (D7210), the periapical x-ray (D0220), and the immediate partial upper denture (D5221) provided on January 16, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the travel and lodging expenses from March 19, 2019 to April 15, 2019.
You asked the Plan to reimburse you for these services. You say that you would like reimbursement for food and expenses after the enrollee's transplant surgery. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that services that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered. The Plan contract says that the Plan will arrange or pay for appropriate lodging and transportation costs for you and a companion for Plan-provided transplant services at a location outside of the pattern of care. We looked at the file and the Plan's rules. The file shows that the Plan reimbursed the transportation and lodging costs for the enrollee's transplant except for a security deposit for rental, application fee for rental, and the purchase of alcohol, wax paper, and storage bags. These services are not related to lodging and transportation for the transplant and are not covered. Therefore, we decided that the Plan does not have to reimburse you for the travel and lodging expenses from March 19, 2019 to April 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 30, 2020.
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 testing is not covered.
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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from October 18, 2020, to October 22, 2020.

You asked the Plan to waive the copayment for SNF care. You say that you believe you should not be held responsible for this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $0 copayment per day for days 1 to 20 and a $165 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted a total of 25 days, these dates of service are days 21 to 25 of the benefit period, resulting in a total copayment amount of $825. 

You have been asked to pay a $0 copayment per day for days 1 to 20 and a $165 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 the SNF care provided from October 18, 2020, to October 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 5, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that the services were medically necessary and you disagree 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on April 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete
mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say
that you would like to appeal these services. The Plan denied your request. The Plan says these services are not
covered under your benefit plan.
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 complete maxillary denture and
complete mandibular denture are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture
(D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport provided September 9, 2020.
You asked the Plan to pay for the ambulance response. You say that that while trying to sort this out you received an invoice for $600 which you paid under threat of collection. According to the manual you received in 2020, your copay for ambulance service is $230. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport provided September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a cystourethroscopy provided on October 12, 2020.
You asked the Plan to pay for the cystourethroscopy. 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 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 a cystourethroscopy provided on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on November 13, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.

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 problem focused limited oral evaluation provided on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on August 25, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomaticpatients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that Cardiovascular Disease Screening must be submitted with CPT codes 80061, 82465, 83718 or 84478. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment panel have not been met. Specifically, this screening is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous immune globulin (IVIG) services provided
on July 6, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says IVIG therapy
will only be considered medically necessary for neurological disorders when there is evidence of rapid
progression of the disease, relapse, or when other forms of treatment have failed.

The Plan must follow Medicare rules. Medicare rules say that IVIG is only covered under certain medical
indications.

We looked at the file and Medicare rules. In this case, there are insufficient medical records that shows the
services were provided in an acute situation, such as prevention of infection. Based on this information, we
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have
to pay for the intravenous immune globulin (IVIG) services provided on July 6, 2020.