Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical information or indication as to why this request is medically necessary.
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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not include a complete sleep history. here is no quantification of excessive daytime sleepiness. There is no mention of observed apneas. There is no detailed upper airway examination, and no neck circumference. The PSG is considered 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the 6 crowns (D2750) provided on September 17, 2020.
You asked the Plan to reimburse you for the dental services. You say that you feel that the copayment is incorrect. The Plan denied your request. The Plan says there is a $275 copayment for each crown. The Plan also says that if the services of a dental lab are required for any procedure, you are responsible for the full laboratory cost, not to exceed the actual amount billed by the lab.
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, there is a copayment of $275 for each crown. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. The record shows that the crowns you received were upgraded which requires a dental lab. The Evidence of Coverage clearly states that if the services of a dental lab are required for any procedure, you are responsible for the full laboratory cost, not to exceed the actual amount billed by the lab. Additionally, the record shows that you signed a treatment plan prior to receiving the services which show that you accepted the treatment estimate based on insurance information presented. Therefore, we decided that the Plan does not have to reimburse you for the 6 crowns (D2750) provided on September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new complete lower limb prosthesis for the enrollee.
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says the request for new complete lower limb prosthesis does meet Medicare criteria as reasonable and necessary
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 prosthesis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested prosthetic leg with advanced foot and ankle feature are not medically necessary as the documentation does not reveal objective medical records from the enrollee's treating medical physician/provider supporting the need for a new prosthetic leg with advanced foot and ankle features. 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 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a new complete lower limb prosthesis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission and care.
You asked the Plan to pre-approve the SNF admission and care. You say that the enrollee is already residing in the SNF, and still needs continued care. The Plan denied your request. The Plan says criteria for admission to SNF have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission and care. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission and care have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission and care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve continued Skilled Nursing Facility. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued Skilled Nursing Facility. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has made little to no progress with therapy-related goals. Skilled therapy services are not needed on a daily 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 continued Skilled Nursing Facility have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right eye cataract surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this needs to be approved, as it meets the criteria. The Plan denied your request. The Plan says further documentation of symptoms is necessary to determine medical necessity.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is not clearly documented that the enrollee has decreased ability to carry out activities of daily living. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve right eye cataract surgery for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 15, 2020.
You asked the Plan to waive the copayment for emergency care. You say that they did not do an X-ray so you should not owe the $80 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 an $80 copayment for emergency care. The medical records show that you received emergency care on September 15, 2020. Therefore, you are responsible to pay the $80 copayment. You have been asked to pay an $80 copayment for emergency care. Emergency care 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 emergency care provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a physical therapy evaluation.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 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 mechanism. Our reviewer says that the requested mechanism is not medically reasonable or necessary. Our physician reviewer found the seat lift is not likely to effect improvement in your condition; or arrest or retard deterioration in your condition. The records do not show that you are incompletely incapable of standing from a chair in the home. You have the ability to ambulate. 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 mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you qualify for an acute inpatient stay according to the Medicare guidelines. The Plan denied your request. The Plan says your request for IRF services is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show recent injury, surgery, or objective evidence of instability.
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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no documented recent injuries or surgeries to the knees. There is no knee instability documented on exam. The pain is noted to have had an atraumatic onset with no documentation of any recent surgical procedures. Therefore, the request for knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control is not medically reasonable or 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of Prolia provided on October 7, 2020.
You asked the Plan to waive the coinsurance for injection. You say that your doctor chose to give you this injection outside of his office. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Prolia. The allowed amount of this claim is $909.20, resulting in a coinsurance obligation of $181.84. You have been asked to pay 20% coinsurance for injection. Injection falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection of Prolia provided on October 7, 2020.
Please note that this decision is only regarding the charges for Prolia on October 7, 2020. Please contact the Plan regarding appeals for any other items or services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on June 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for durable medical equipment. You say that you thought that you received prior authorization. You say that you did not know there was a difference between authorization and a referral. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available to provide this equipment.
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 had network providers available who could have provided 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 durable medical equipment provided on June 9, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on August 1, 2020, through September 10, 2020.

You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this service is not durable medical equipment and was not delivered to the member's home. The Plan denied your request. The Plan says this code is not recognized for out-of-network provider.

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 find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9324 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on August 1, 2020, through September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental, investigational, and unproven.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation in efficacy that has been reported. Therefore, the procedure is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 7, 2020.

You asked the Plan to pay for the dental service. You say that you understand that periodontal cleaning is more expensive. You also say that the Plan should at least apply the amount they would normally pay for a regular cleaning to this service. The Plan denied your request. The Plan says periodontal maintenance is not a preventive dental service. The Plan also says that periodontal maintenance is a post-therapeutic procedure used to maintain the results of periodontal therapy, not to prevent disease in healthy patients.

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 items or services are not among those covered under this benefit. The Evidence of Coverage clearly states that only preventive services are covered. Periodontal maintenance is not a preventive dental service. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on September 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The claim was not billed with a valid primary diagnosis code. 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 pay for the services rendered on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99222) provided on July 21, 2019.

You asked the Plan to pay for hospital care. You say that these medically necessary services were provided to the enrollee in good faith and you feel that the provider is entitled to reimbursement for the services rendered. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for hospital care was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital care (99222) provided on July 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician service. You say that the provider depends on the facility staff to obtain authorizations as needed. You also say that these services should be paid so as to avoid penalizing the provider due to the facility's failure to obtain proper authorizations. The Plan denied your request. The Plan says prior authorization was not obtained before the services were provided. The Plan says that the services provided were not urgent or emergent. The Plan also says that the service could have been provided by an in network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 medical services provided on July 28, 2020 by an out of network (OON) provider.