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

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve inpatient rehabilitation facility (IRF) service. You say that you need to start rehabilitation as soon as you can to recover. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can receive IRF care from an in-network facility.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride visit provided on September 30, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that this charge should be considered as a part of your inpatient stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for each one-way Medicare-covered ambulance transport. You have been asked to pay a $175 copayment for the ambulance ride. The ambulance ride falls 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 the ambulance ride provided by on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 2, 2018.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have gum disease and these services were necessary. The Plan denied your request. The Plan says these services exceed the frequency limitations set in 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, periodic oral exams and dental prophylaxis (cleanings) are each limited to 2 per 12 months. The record shows that you received periodic oral evaluations and prophylaxes on February 28, 2018 and April 24, 2018 and your periodic oral exams and dental prophylaxis (cleanings) benefits were then exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 2, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for assay of Homocysteine (83090) provided September 4, 2019.
You asked the Plan to pay for assay of Homocysteine. You say that this testing was medically necessary. The Plan denied your request. The Plan says this service was provided for screening purposes.
The Plan follows Medicare rules. The rules say that once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. 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 assay of Homocysteine. Our reviewer says that assay of Homocysteine was not medically necessary in this case. Our physician reviewer found there was no subjective documentation of symptoms or objective documentation of previous abnormal levels or rationale for testing was submitted. The test at issue in this case was not medically necessary for the diagnosis or treatment of an illness.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of assay of Homocysteine have not been met. Therefore, we decided that the Plan does not have to pay for assay of Homocysteine (83090) provided September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for open procedures involving hip joint; not otherwise specified (01210-QX) provided June 11, 2019.
You asked the Plan to pay for code 01210-QX. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the medical records do not support billing the code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 code 01210-QX. Our reviewer says that code 01210-QX is not supported by the medical records. Our physician reviewer found the medical records provided do not include documentation of an anesthesia start and stop time required for CPT code 01210, therefore, the service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 01210-QX have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for open procedures involving hip joint; not otherwise specified (01210-QX) provided June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on September 12, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you have had this Plan for over 10 years and never had an issue. You also say that you are living alone on social security. The Plan denied your request. The Plan says these services are not covered by Original Medicare. The Plan also says that they cover medically necessary dental services, as covered by Original Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for 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 pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.
You asked the Plan to pre-approve these services. You say that your previous dentures did not fit properly. The Plan denied your request. The Plan says the request exceeds the benefit limit.
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 one upper complete and/or lower complete denture every five years. We looked at the file and the Plan's rules. The file shows that you received upper and lower dentures on January 31, 2019 for which the Plan approved and paid. You are not eligible for new dentures until five years have passed from this date. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study described by code 95810.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The rules say that, for edits with the modifier indicator of 0, the Column 2 code cannot be paid regardless of whether a modifier is used. The services at issue are a sleep study described by code 95810. This code is a column 2 code with a modifier indicator of 0 when billed with column 1 code 95811. The Plan has approved a sleep study for you under code 95811. Code 95810 is therefore not approved. Therefore, we decided that the Plan does not have to pre-approve a sleep study described by code 95810.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 1, 2019.
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 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 physician's services provided on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transports for the enrollee.
You asked the Plan to approve these services. You say that the enrollee needs transportation to dialysis. The Plan denied your request. The Plan says further trips are not covered.
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. The file shows that the enrollee has used 22 of the 24 total one-way trips allowed by the supplemental benefit. Once the enrollee has used all 24 of the one-way trips, further trips are not covered by Medicare or the supplemental benefit. Therefore, we decided that the Plan does not have to approve additional routine transports for the enrollee.
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 are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you
were admitted to the hospital on January 30, 2020 with a tibia fracture after a auto versus bicycle accident. You
underwent surgical repair for the fracture. You had stable vital signs and received physical and occupational
therapy in the hospital. You need varied assistance with activities of daily living and are able to walk 15 feet
with a rolling walker. You have no skilled nursing needs. You have skilled therapy needs but do not require
skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient
basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Lupron injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found this injection is the standard of care in this case for metastatic prostate cancer. Therapy is clearly indicated. 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Lupron injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 10, 2020 with schizophrenia, Bipolar 2 disorder, and cocaine use disorder. It is not expected that he will improve in a reasonable period of time, as he is not showing dangerousness to self or others and does not have auditory or visual hallucinations. He is not showing any behavioral issues. The services are not expected to improve his condition or for the purpose of diagnosis. The inpatient psychiatric services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services for the enrollee.
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the member can receive the necessary care at a lower level 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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services. The enrollee can continue to receive any needed acute medical care in his current 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and grab bars.
You asked the Plan to pre-approve a shower chair and grab bars. You say that you are still recovering from a previous fall which makes it difficult to get in and out of your tub while safely using the shower once inside. You say that you believe the requested items will help prevent another fall and the subsequent treatment that would come along with it. You stated that you are on a limited income and cannot afford the items yourself. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab bars are not covered because they are not primarily medical in nature. While a shower chair and grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and grab bars.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tacrolimus for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve tacrolimus for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis confirmed on x-rays that has failed conservative treatment. He has not tried and failed the plan's required drugs of orthovisc and monovisc and the records do not support that the required drugs would be less effective or contraindicated. Synvisc is therefore not reasonable or medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4260), and the bone replacement graft (D7953) provided from June 28, 2019 to August 15, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental services you received 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, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4260), and the bone replacement graft (D7953) provided from June 28, 2019 to August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve these services. You say that you need the equipment for travel. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.