Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvethe Dexcom CGM.You asked the Plan to pre-approvethe Dexcom CGM. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plan says that there is no clinical information to determine the medical necessity of this supply.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meetcriteria referenced 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 Dexcom CGM. Our reviewer says that the member meets criteria for the requested CGM. Our physician reviewer found the member is testing four times per day and using insulin 4 times per day. The member adjusts their does according to their bloog glucose level.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 Dexcom CGM have been met.Therefore, we decided that the Plan has to pre-approvethe Dexcom CGM.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided 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 do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF due to poor endurance and resistance to participate. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided August 19, 2020, to August 28, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 $395 copayment per day for days 1-5, no copayment for days 6-90 for inpatient hospital care. You have been asked to pay a total cost share of $1660 for the inpatient hospital care (5 days x $395 copayment). The service provided falls within the inpatient hospital 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 inpatient hospital care provided August 19, 2020, to August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services and wound care provided by a participating provider on September 9, 2020, to September 24, 2020.You asked the Plan to waive the copayment forphysician services and wound care. You say that you did not know this was considered an outpatient surgery. The Plan denied your request. The Plan says the correct copayments have 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 $275 copayment and a $40 copayment for outpatient surgery/network/outpatient hospital and physician/practitioner services/network/specialist. You have been asked to pay a $275 copayment for wound care and a $40 copayment for physician services. Physician services falls within the physician/practitioner services/network/specialist benefit category and wound care falls within the outpatient surgery/network/outpatient hospital 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 physician services and wound care provided by a participating providr on September 9, 2020, to September 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for the Watchman implant with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthis procedure is now available within the plan's 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, outof 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 Plandoes not haveto pre-approvea referral for the Watchman implant with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the omalizumab injection services received on June 26, 2020.
You asked the Plan to waive the coinsurance for the omalizumab injection services. You say that you have assistance to pay for the injections. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Part B drugs that are administered by a provider. You have been asked to pay 20% coinsurance for the omalizumab injection services. The omalizumab injection services falls within the Medicare Part B drugs 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 the omalizumab injection services received on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided from November 17, 2019, through November 20, 2019.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $372 copaymenteach day, for days 1-5 for inpatient hospital care. You have been asked to pay$1,116 ($372 copayment x 3 days) forthe inpatient hospital care provided. 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 copaymentfor the inpatient hospital care provided from November 17, 2019, through November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown provided on July 30, 2020.
You asked the Plan to pay for the retainer crown. You say that you were advised by the Plan that a portion of the bridge would not be covered. The Plan denied your request. The Plan says the frequency limit has been satisfied, and the third crown cannot be approved.
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, crowns are limited to two procedures per calendar year. The record shows that due to misinformation given, the Plan has made a one-time exception and covered the two pontics provided on July 30, 2020 at the in-network benefit rate, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the retainer crown provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 11, 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 out of network physician services provided to the enrollee on June 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you need additional trips for appointments. The Plan denied your request. The Plan says you have exhausted your routine transportation 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 one-way trips per year. We looked at your request, the records in the case file, and the rules. 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 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that thePlan does not have to pre-approvediagnostic medial branch blocks.You asked the Plan to pre-approvediagnostic medial branch blocks. You say that the requested diagnostic medial branch blocks are medically necessary.The Plandenied your request. The Plan says the enrollee does not meet criteria for the requested diagnostic medial branch blocks.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 diagnostic medial branch blocks. Our reviewer says that the enrollee does not meet criteria for the requested diagnostic medial branch blocks. Our physician reviewer found the enrollee has thoracic back pain without radiation. He is status post a spinal cord stimulator for persistent pain following back surgery. He has not had physical therapy or recent imaging of the thoracic spine. 
The enrollee has not had a trial of physical therapy for the thoracic spine or recent imaging of the thoracic spine.  The request is considered not medically reasonable or necessary at this point.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diagnostic medial branch blocks have not been met.Therefore, we decided that the Plan does not have to pre-approvediagnostic medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 27, 2020.You asked the Plan to pay for the physician's services. 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 requireenrollees 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 Plandid not pre-approve the physician's services. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's servicesprovidedon August 27, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided August 12, 2020, to September 2, 2020.
You asked the Plan to pay for the acupuncture services. You say that acupuncture is medically necessary for your medical condition. The Plan denied your request. The Plan says they failed to obtain from your provider how many acupuncture appointments you have received.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan requested additional information from your provider detailing how many acupuncture appointments you have received. Your provider did not provide an adequate response to this request detailing how many appoints were provided. Without this information, it is not known if you've received more than 20 sessions this year. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided August 12, 2020, to September 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient therapy services provided to the enrollee from June 16, 2020, to June 30, 2020.You asked the Planto pay forthis service. You say that these services should be covered by the Plan.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 foroutpatient therapy services provided to the enrollee from June 16, 2020, to June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care (readmission) provided to the enrollee from December 4, 2019, to December 9, 2019.
You asked the Plan to pay for inpatient-only services provided to the enrollee. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria for readmission were not met.
The Plan must follow Medicare rules. Medicare covers inpatient services demonstrated to be medically necessary. We asked our Physician Reviewer to look at the Medicare rules and the case file to determine if the services provided were medically necessary. Our physician review says that the enrollee had cardiac arrest. The review of the records shows this was an acute event that represented a rapid deterioration from an acute event. This did not present itself as a progressive syndrome with complication. Inpatient coverage criteria were met. Therefore, we decided that the Plan has to pay for inpatient care (readmission) provided to the enrollee from December 4, 2019, to December 9, 2019.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation services provided on May 17, 2020.You asked the Plan to pay forthe transportation services. You say that the services should be covered.The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related tothe terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe transportation services provided on May 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network podiatry services provided on March 6, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says you 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 forout of network podiatry services provided on March 6, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services provided on March 4, 2020.You asked the Plan to waive the copayment forthe laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $20 copayment for Medicare-covered non-preventive lab services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory services on March 4, 2020. You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 forthe laboratory services provided on March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show the enrollee requires daily skilled nursing and daily skilled therapy services at a SNF level of care.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility(SNF) services for the enrollee.