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

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings 
provided on June 15, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that it was your 
understanding that it did not matter what dentist you went to for your cleanings and preventive care. You also 
say that you were never told to make sure that the dentist was participating in Medicare. The Plan denied your 
request. The Plan says the treating provider has opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation, prophylaxis, and bitewings provided on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 18, 2019, to 
October 21, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that he enrollee could have been treated in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department on October 18, 2019, with altered mental 
status and combative behavior. The evening before the admission, the members combative behavior began and 
the daughter called emergency medical services (EMS). The member was given 10 milligrams (mg) of Versed 
on the way to the hospital. In the emergency department, the members vital signs were stable. The member 
was admitted for possible urinary tract infection (UTI). She was treated with intravenous (IV) antibiotic 
Ceftriaxone, every 24 hours. The member also underwent other testing. Her condition stabilized and improved 
and she was discharged when considered medically stable on October 21, 2019. The review has determined 
that the record show that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care would span two midnights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric care provided from March 14, 2020, to March 20, 2020.
You asked the Plan to pay for the inpatient psychiatric care. You say that the enrollee requires an inpatient level of care to manage her condition. The Plan denied your request. The Plan says the enrollee was stable and did not require an inpatient level of psychiatric care based on her presentation.
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 pay for the inpatient psychiatric care. Our reviewer says that the inpatient level of care does not appear to be medically reasonable and necessary in this case. Our physician reviewer found This 52-year-old female was admitted to the acute inpatient psychiatric hospitalization on March 14, 2020 with Disorganized Schizophrenia and Schizoaffective Disorder Depressed
Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric care provided from March 14, 2020, to March 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled services provided on May 12, 2020.
You asked the Plan to pay for the skilled services. You say that the claim should be paid. The Plan denied your request. The Plan says the records do not document that the physician has ordered these additional services.
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 health care services. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled services have not been met. The records do not document that the physician has ordered these additional services. Therefore, we decided that the Plan does not have to pay for the skilled services provided on May 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehydrocodone acetominophen.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied 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-approvehydrocodone acetominophen.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the inpatient mental health care provided 
from February 9, 2020 to February 14, 2020. 
 
You asked the Plan to adjust 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 services 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 $195 
copayment per day, for days 1-6 and a $0 copayment per day, for days 7-90, for inpatient mental health care.  
 
You have been asked to pay $975 ($195 copayment x 5 days) for the inpatient mental health 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 adjust the copayment for the inpatient mental health care provided from February 9, 
2020 to February 14, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the patient requires intensive therapy and close 
physician monitoring. The Plan denied your request. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently 
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that the patient's 
functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute 
care facility. 
 
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. The patient 
appears to be improving slowly and requires additional short term acute care services (less than 25 days) for 
additional weaning and monitoring. The patient does not require services at the LTACH that are not already 
being provided at the current facility. There are no services at the LTACH that the patient requires that is not 
already available and covered at the current facility. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone scan.You asked the Plan to pre-approvea bone scan. You say that the records provided support the need for the requested scan.The Plan denied your request. The Plan says there is insufficient clinical information to support the requested study. The Plan says that there is not a detailed clinical evaluation and history, relevant laboratory studies, and prior imaging which shows a reason for further imaging being needed.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a bone scan. Our reviewer says that a bone scan is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back and hip pain. There is no medical justification for a bone scan. More information would need to be provided to justify the use of a scan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea bone scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric hospital services for the enrollee beginning October 13, 2020.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee has no acute symptoms that require 24 hour inpatient care.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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee in this case. This enrollee does not require inpatient mental health treatment as he is not a danger to himself or others and does not have any auditory or visual hallucinations or behavioral issues. It does not appear that active treatment is taking place. It does not appear that the services are reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospitalservices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric hospital services for the enrollee beginning October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute care facility.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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria forLTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you must keep weight off your foot. The Plan 
denied your request. The Plan says that there is no evidence that a knee scooter has been proven necessary 
above crutches or a wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a knee scooter. Our physician reviewer 
found that you had right foot pain. Per the documentation, you have radiographic evidence of mild 
degenerative joint disease to the talonavicular joint and first metatarsophalangeal joint. You are wearing a boot. 
The review indicates that you have tried a standard walker, but that does not keep weight off your foot. The 
review has determined that the requested knee scooter is medically reasonable and necessary over the standard 
cane, crutch, or wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee scooter have been met. Therefore, we decided that the Plan has to pre-
approve a knee scooter.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require the intensity of services provided at an IRF. 
 
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 physician reviewer found 
that the enrollee presented to the acute hospital with an acute left sided intracranial hemorrhage. She was 
treated in the hospital with neurosurgical consultation and embolization of an arterio-venous malformation. She 
is weak and de-conditioned and is working with physical and occupational therapy. She is walking 120 feet with 
a front wheel walker with moderate assistance, is moderate assist for transfers, and moderate to maximum 
assist for most activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical and occupational therapy services, but she does not require an intensive 
inpatient rehabilitation therapy program. 
 
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-approvea Clinitron bed for the enrollee.You asked the Plan to pre-approvea Clinitron bed. You say that the enrollee requires this bed.The Plan denied your request. The Plan says that this specific bed is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred brands.We looked at the file and Medicare rules. The file indicates that Plan approved an air fluidized bed for the enrollee but you are specifically requesting a Clinitron air fluidized bed. The enrollee's treating physician has indicated that a specific air fluidized bed is not medically necessary for the enrollee and the one approved by the Plan will meet the enrollee's medical needs. Based on this information, we decided that Medicare rules for coverage of a Clinitron bed have not been met.Therefore, we decided that the Plan does not have to pre-approvea Clinitron bed for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral surgery services provided on April 27, 2020. 
 
You asked the Plan to pay for the oral surgery. You say that you were in a great deal of pain and were told to 
go to this provider. You state that you checked and there were no network oral surgeons within a reasonable 
distance from your home. The Plan denied your request. The Plan says this surgery is considered dental in 
nature. It is not one of the limited dental services covered by Medicare and is not among those services covered 
by your supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Additionally, this does not meet the criteria to be considered a medical 
service. This was treatment of a periapical lesion. A periapical lesion is a condition of the tooth root, 
periodontal membrane and alveolar bone. As such, treatment of this condition is treatment of the tooth and 
structure directly supporting the teeth. Therefore, we decided that the Plan does not have to pay for the oral 
surgery services provided on April 27, 2020.