Persius/hicric huggingface dataset:
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for the endodontic therapy (root canal) (D3330) and pay for the unspecified preventative procedure (D1999) provided on September 30, 2020.

You asked the Plan to waive or reduce the coinsurance for the root canal and pay for the unspecified preventative procedure. You say that you were initially told that you would owe a smaller amount and are frustrated to have an additional bill. You feel the Plan should cover this amount due to an error in the initial quote. The Plan denied your request. The Plan says comprehensive dental services require 50% coinsurance after you meet your $50 deductible. This amount was applied correctly. The unspecified preventative procedure is not covered by Medicare or by the Plan's supplemental dental benefit.

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 $50 deductible for comprehensive dental services and 50% coinsurance for endodontic services.

You have been asked to pay $489.50 for a root canal (endodontic therapy). The Plan's allowed amount for this service (the most that the provider is allowed to bill) is $929. You must meet your $50 deductible for comprehensive services before the Plan will pay their share, which leaves $879.

You must pay 50% coinsurance on this amount, which totals $439.50 ($879 x 50% = $439.50). Your total cost is the deductible amount and your coinsurance ($439.50 +$50 = $489.50). 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 or reduce the copayment for the endodontic therapy (root canal) (D3330) provided on September 30, 2020.

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 requested unspecified preventative procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on September 30, 2020.

Your complaint about a possible misquote or miscommunication in cost from the Plan or provider's office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 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 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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 waive the copayment for the office visit provided on February 12, 2018.
You asked the Plan to waive the copayment for the office visit. You say that you are appealing a bill you received from 2018. The Plan denied your request. The Plan says you have been asked to pay 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 $10 copayment for each Medicare-covered primary care doctor visit. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on February 12, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need acute rehab. The Plan denied your request. The Plan says the services are 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 in the Medicare rules section. 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 medically necessary. Our physician reviewer found you were admitted to the hospital for respiratory failure and COVID-19 pneumonia. Your medical problems are now stable and you have no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may benefit from further therapy, you do not require an intensive therapy program in an IRF and there is not a reasonable expectation that you would be able to fully participate in and benefit from an intensive therapy program in the IRF. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 14, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you live alone and you could not have driven. The Plan denied your request. The Plan says the copayment applied correctly.
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 $265 copayment per date of service regardless of the number of trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport 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 transport provided on November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624).
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS device is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration has stated that the CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The medical record does not indicate the class of heart failure. The records submitted indicate that the reason for hospital admission as hypoxic respiratory failure. The requested device is not 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 the CardioMEMS device. have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 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.
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 Group 3 power wheelchair with multiple power options (K0861).
You asked the Plan to pre-approve the requested type of Group 3 power wheelchair. You say that it is felt that the type of wheelchair requested is medically necessary. The Plan denied your request. The Plan says the documentation does not support the need for the specific type of wheelchair being requested.
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power options is only covered when the enrollee has one of the conditions listed in the Medicare rules section. 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 requested type of Group 3 power wheelchair. Our reviewer says that the requested power wheelchair is not considered reasonable and necessary in this case. Our physician reviewer found the patient does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence to support the patient is at high risk for a pressure ulcer. While he does meet the criteria for a Group 3 power wheelchair since his mobility deficit is related to a neurological condition, the wheelchair with multiple power options appears to exceed his medical need. 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 requested type of Group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G powered upper extremity device coded as L8702.
You asked the Plan to pre-approve the MyoPro Motion G device. You say that it is felt that this device would clearly assist the enrollee in using her arm and improving participation in daily living activities. The Plan denied your request. The Plan says there is not sufficient information to support the use of this device.
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 MyoPro Motion G device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of incomplete spinal cord injury with chronic left hemiparesis. It is noted that standard rehabilitation techniques and bracing have failed to improve the enrollee's condition and level of function. At this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis from the patient's spinal cord injury than any available standard therapy such as conventional treatments. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving health outcomes in patients with spinal cord injuries. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 MyoPro Motion G device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G powered upper extremity device coded as L8702.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you do not feel ready for a safe discharge and you will not be able to function at home. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an IRF admission does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 does 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 inpatient rehabilitation facility due to your level of immobility and non-weight bearing status. Continued care in the long-term acute care hospital is appropriate until you are stable to transfer to a lower level of care such as a skilled nursing facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on October 20, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you were told to go to the ER because you had a test done that showed you were having a heart attack. You say that the doctor's told you that you did not have a heart attack. You say that you should not have to pay for this emergency room visit. The Plan denied your request. The Plan says the correct copayment has 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 $120 copayment for emergency care. 

You have been asked to pay a $120 copayment for an emergency room visit. Since emergency care services were provided to you, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit provided by a participating provider on October 20, 2020.

We note your complaint about the ECG machine not working properly. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and periapical x-ray (D0220) provided on December 14, 2020.
You asked the Plan to pay for the dental services. You say that you did not receive an excessive amount of regular cleanings during the specified timeframe. You say that the x-ray was needed because the dentist was no able to read the previous one. You also say that you should not be responsible for an error made by the provider's office. The Plan denied your request. The Plan says 2 prophylaxis are covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that periapical x-ray is not listed as a covered service.
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 and prophylaxis is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you received on June 11, 2020, and September 30, 2020. Additionally, periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and periapical x-ray (D0220) provided on December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on October 28, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you think that this was not codded correctly. The Plan denied your request. The Plan says the correct copayment has 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 $200 copayment for outpatient surgery/in-network. You have been asked to pay a $200 copayment for an outpatient surgery. The injection that you received is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating on October 28, 2020.