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

We decided that the Plan has to pre-approve the periodontal scaling and root planing for all 4 quadrants. We decided that the Plan does not have to pre-approve a crown and a prefabricated post and core in addition to a crown for tooth # 31.
You asked the Plan to pre-approve the periodontal scaling and root planing for all 4 quadrants. The Plan says that the periodontal scaling and root planing is not medically necessary. The Plan also says crowns and prefabricated post and core in addition to a crown are not listed as covered services.
We decided that the Plan has to pre-approve the periodontal scaling and root planing for all 4 quadrants. 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 dental services 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 dental services. Our reviewer says that the periodontal scaling and root planing for all 4 quadrants is medically necessary. Our physician reviewer found based on the provided documentation there are multiple areas of pathologic periodontal pockets and multiple areas of subgingival calculus accumulation it is my opinion that the criteria for coverage for periodontal scaling and root planing (D4341) have been met. 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 dental services have been met. Therefore, we decided that the Plan has to pre-approve the periodontal scaling and root planing for all 4 quadrants.
We also decided that the Plan does not have to pre-approve a crown and a prefabricated post and core in addition to a crown for tooth # 31.
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown and prefabricated post and core in addition to a crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown and a prefabricated post and core in addition to a crown for tooth # 31.
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires this level of care. The Plan denied your request. The Plan says the enrollee does not require any service that cannot be provided in the current 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. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, analgesia, total parenteral nutrition, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: 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 the enrollee requires an acute level of care in the long term which is better provided in a specialized setting. The Plan denied your request. The Plan says an LTACH does not offer a specialized setting that is clinical superior to simply staying in the current facility until no further hospital care is needed.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator support and weaning, tracheostomy care, chest tube care, surveillance laboratory studies, intravenous antibiotics, tube feeding, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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 pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visit. You say that you have used this provider before. You say that the provider was able to see you within 24 hours. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 office visits to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 80327 provided on December 18, 2018.
You asked the Plan to pay for CPT code 80327. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the service is not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 80327 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for CPT code 80327 provided on December 18, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from August 16, 2019 to August 22, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for another inpatient admission. You say your father had to be transferred in order to do the cardioversion procedure. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for each day, day(s) 1-5 and a $0 copayment, days 6+. The enrollee has been asked to pay a $350 copayment for the inpatient hospital stay. ($350 x 5 = $1,750). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 16, 2019 to August 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physician oversight to get her strength and mobility back. The Plan denied your request. The Plan says there is no medical complexity that supports the need for supervision by a rehab physician three times a week.
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 was admitted to an acute hospital with complaints of dizziness. The enrollee now has controlled blood pressures, and is in sinus rhythm. The complexity of enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is at minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on September 13, 2019.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the service was rendered by a non-participating provider without 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 an x-ray provided on September 13, 2019.
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 the services are necessary. The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, 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 based on the provided medical records the enrollee is receiving the necessary services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 4, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty group 2 power wheelchair (K0825).
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically necessary to enable the member to get around. The Plan denied your request. The Plan says the power wheelchair is not medically necessary for the member.
The Plan follows Medicare rules. Medicare rules say that a power wheelchair will be covered if the member's weight is less than or equal to the weight capacity of the wheelchair, the member's home provides adequate access between rooms and the use of the wheelchair will significantly improve the member's ability to participate in MRADLs. 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 power wheelchair. Our reviewer says that the Group 2 Heavy Duty power wheelchair is not medically necessary based on the submitted documentation. Our physician reviewer found the member's weight is not indicated in the medical records to indicate whether she is the appropriate weight capacity for the requested wheelchair. There is no objective evaluation of the member's home that indicates it provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is requested. It is not clear that the power wheelchair will significantly improve the member's ability to participate in MRADLs.
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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty group 2 power wheelchair (K0825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the waterproof tape provided on August 27, 2019 by OON provider.
You asked the Plan to pay for the waterproof tape (A4452). You say that the waterproof tape is a covered item. The Plan denied your request. The Plan says you did not request 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 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 waterproof tape provided on August 27, 2019 by OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SpaceOAR system.
You asked the Plan to pre-approve the SpaceOAR System. You say that the procedure should be considered as reasonable and necessary to reduce his risk of rectal morbidity. The Plan denied your request. The Plan says there is insufficient evidence to adequately address the use of the SpaceOAR System.
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 the SpaceOR System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found additional study is needed to corroborate the findings of the pivotal randomized controlled trial, to determine which patients are likely to benefit from the use of a spacer, and to fully understand the long-term safety and efficacy of this technology. The evidence is insufficient to determine the effects of the technology on health outcomes. 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 SpaceOR System have not been met. Therefore, we decided that the Plan does not have to pre-approve a SpaceOAR system.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided from April 22, 2019 to April 30, 2019.
You asked the Plan to pay for the skilled nursing facility services. You say that the enrollee was not enrolled in hospice while at your facility. You also say that the enrollee was pre-approved by the Plan for her rehabilitation stay. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 22, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services provided from April 22, 2019 to April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wig purchased on July 9, 2019.
You asked the Plan to pre-approve the wig. You say that you have lost all of your hair because of my cancer treatment. The Plan denied your request. The Plan says this item is not a covered benefit.
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 the wig purchased on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Review of the records show that the services are not authorized because they are a Part-A benefit for skilled nursing facility (SNF) admissions and are included in the facility PPS payment. The facility received Medicare Part- SNF payment and is responsible to provide all services and pay any and all vendors. Therefore, we decided that the Plan does not have to pay for the DME provided to the enrollee on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on September 24, 2019.
You asked the Plan to pay for the refraction. You say that you would like payment made for this service. The Plan denied your request. The Plan says that the provider is not participating for your routine vision plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received through a certain practice. We looked at the file and the Plan's rules. The file indicates these services were not received through this practice. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on September 24, 2019.