Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crown for tooth #30.
You asked the Plan to pre-approve the crown for tooth #30. The Plan denied your request. The Plan says that the documentation does not support the necessity for services.
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 Plan covers the crown for tooth #30 when the services are medically necessary and reasonable. 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 crown for tooth #30. Our reviewer says that the criteria for coverage has been met. Our reviewer found that a stainless-steel crown is a long-term method of covering a damaged tooth and it is anticipated to be replaced a future point. Our physician reviewer also found that given the relatively shorter life span of the stainless-steel crown, it would be reasonable and appropriate to place a standard permanent crown on tooth #30. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for tooth #30 have been met. Therefore, we decided that the Plan has to pre-approve the crown for tooth #30.
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: 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 you need physical therapy to get you back on your
feet. The Plan denied your request. The Plan says that your current needs can be managed at a lower level of
care such as a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You
are medically stable with no evidence of need for supervision by physical medicine and rehab Physician or
need for acute rehab nursing care. Functionally you need physical therapy (PT) and occupational therapy (OT)
but do not require IRF level of therapies. You may benefit from further PT and OT but do not require an
intensive therapy program. 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: 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 IRF level care is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the records do not indicate that there are significant or complex medical or nursing
issues that could not be addressed at a Skilled Nursing Facility (SNF) level of care. Ongoing pain medication
and other medication management, wound and skin care, and daily therapy can be provided at a SNF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 not intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available from the acute hospital. The enrollee should remain in place until it is appropriate to transfer them to a lower level of care such as a Skilled Nursing Facility.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home INR monitoring materials and equipment provided to the enrollee from September 17, 2019 to September 23, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the frequency for this code has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0249 is "Provision of test materials and equipment for home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests." We find that HCPCS code G0249 is not supported in the medical record. Specifically, this code was billed 25 days after the previous claim. This code can only be billed once a month, and encompasses four tests, one per week. 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 for home INR monitoring materials and equipment provided to the enrollee from September 17, 2019 to September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 6,
2020.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that another exam was needed. You
say that you were informed you were fully covered. The Plan denied your request. The Plan says only one
procedure per plan year is 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 Plan also has a maximum benefit
of one limited oral evaluation per plan year. The Plan paid for a limited oral evaluation provided on January 13,
2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited
oral evaluation (D0140) provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions (D7140) provided on March 16, 2020.You asked the Plan to pay more for the extractions (D7140). You say that you had to see an out-of-network dentist because you were in pain and needed your teeth pulled.You say that the bill should be treated as in-network. The Plan denied your request. The Plan says the claim 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 allowed amount for extractions. Therefore, we decided that the Plan does not have to pay more for the extractions (D7140) provided on March 16, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy services.You asked the Plan to pre-approve endodontic therapy services. 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.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve endodontic therapy services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the diabetic shoes (A5500) and inserts (A5514) purchased on January 8, 2020.You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the coinsurance was applied correctly to the durable medical equipment purchased.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for each Medicare-covered pair of therapeutic shoes or inserts.The Plan says you must pay a $70.36coinsurance for the diabetic shoes and inserts purchased. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for each Medicare-covered pair of therapeutic shoes or inserts.Therefore, we decided that the Plan has to waive the coinsurance for the diabetic shoes (A5500) and inserts (A5514) purchased on January 8, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 21, 2019.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 claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an office setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 57.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 21, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay fora duplex scan (CPT 93926) provided to the enrollee on March 4, 2020.You asked the Plan to pay for the scan. You say that this should be paid for.The Plan denied your request. The Plan says that there is no support to allow the billed diagnosis code with CPT 93926.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code is "Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study."Additionally, 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 follows these rules.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 scan. Our reviewers says that the requested scan is supported in the medical records. Our physician reviewer found the provider of the ultrasound study completed the service on the basis of a request from a medical provider. According to the documentation provided, the request for this study originated from a representative of the health plan.  For the purpose of this review, the request for the study by the health care provider satisfies the burden of medical necessity with respect to completion of the study. Under no circumstances should you be billed for this study.We looked at this physician's review, the file, and Medicare rules. You were referred for this study by a contract provider. The file does not show that the Plan provided notice that the scan would not be covered.Under Medicare rules, this means that the scan is considered approved by the plan. Based on this information, we decided that Medicare rules for coverage of the scan have been met.Therefore, we decided that the Plan has to pay for a duplex scan (CPT 93926) provided to the enrollee on March 4, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the CMS criteria for
coverage of LTACH. The Plan denied your request. The Plan says based on Medicare guidelines, the enrollee
does not meet the requirements for approval for LTACH.
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 that based on the documentation provided, it is my opinion that the health plan's
denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for a
fractured hip. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing LTC needs.
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron Emission Tomography (PET) scan (78815) provided on November 8, 2019.
You asked the Plan to pay for the PET scan. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were out-of-network and were not pre-authorized or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 Positron Emission Tomography (PET) scan (78815) provided on November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction provided on January 30, 2020 by an outof-
network provider.
You asked the Plan to pay for the eye refraction. You say that you were told by the providers office that they
are in-network The Plan denied your request. The Plan says you do not have out-of-network benefits.
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.
Review of the file show that you received an eye refraction on January 30, 2020 by an out-of-network provider.
Your EOC states, "Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
For routine vision care, covered services include: eye refractions during a routine exam performed by an innetwork
Vision Care Provider." 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 the eye refraction provided
on January 30, 2020 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 13,
2019 to December 20, 2019 and from December 31, 2019 to January 11, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient SNF level of care.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from December 13, 2019 to December 20,
2019 and from December 31, 2019 to January 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 physical therapy visits You asked the Plan to pre-approve the physical therapy. You say that you would like reconsideration because stopping therapy will increase your caregivers burden and increase your risk of complications.The Plan denied your request. The Plan says you are reaching a level of stability with your physical therapy education and goals.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 healthcare 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 physical therapy. Our reviewer says that the requested therapy is not generally accepted as specific and effective therapy for your condition.  You have had prior extensive therapy and your functional level appears near baseline. The records do not indicate that you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment. Our physician reviewer found the requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish,design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.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 physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve an additional 10 physical therapy visits