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 LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving safe and effective care in the current hospital setting. Care can continue in the current hospital setting until the enrollee is medically ready for a lower level of care.
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 that there is no documentation provided indicating 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 he is 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial foot shoe insert with longitudinal arch.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that foot orthotics are covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the enrollee had his right toes surgically removed. He can function with walking and the requested orthotics are to conserve energy when walking. The records do not show that the orthotics are needed to reach or maintain a defined functional state. The criteria for coverage are not met and the services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial foot shoe insert with longitudinal arch.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for autogenous connective tissue graft procedures (D4273) for three teeth, a surgical splint (D5988) and repair of maxillofacial tissue defects (D7955) provided on March 4, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefits.
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. Therefore, we decided that the Plan does not have to pay for autogenous connective tissue graft procedures (D4273) for three teeth, a surgical splint (D5988) and repair of maxillofacial tissue defects (D7955) provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown and core buildup, including any pins when required provided on April 30, 2021 by an OON provider.
You asked the Plan to pay more for the crown and core buildup. You say that your crown came off and you needed it to be fixed. You also say that you feel you should not have to pay more than what the Explanation of Benefits says because the dentist did not communicate all of the options that were available to you. The Plan denied your request. The Plan says this claim processed correctly under your non-participating benefits. The Plan also says that you signed a financial agreement with the provider for these services.
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. Therefore, we decided that the Plan does not have to pay more for the crown and core buildup, including any pins when required provided on April 30, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital after care.
You asked the Plan to pay for acute inpatient hospital after care. You say that you do not have enough money to pay for an inpatient stay if this will not be approved. The Plan denied your request. The Plan says your care could be provided without an inpatient stay after your surgical procedure. You don't meet any of the requirements for an inpatient stay.
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 after care. Our reviewer says that the documentation does not support that the criteria for inpatient after care are met in this
case. Our physician reviewer found this case, the record indicates that you are scheduled for a total hip arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. You may be admitted for observation. The elements of the coverage rule are not satisfied. The requested service is not recommended We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital after care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital after care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is considered experimental in nature, as more research is needed to support efficacy. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81401, 81479, 82955) provided on October 14, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81240, 81241, 81291, 81355, 81400, 81401, 81479, 82955) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve oncology services. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says this care can be provided safely within network.
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 oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need the IRF services to help you get on your feet and walk again because in home therapy does not work. The Plan denied your request. The Plan says the request for admission to an IRF remains denied as not medically necessary. The Plan also says that your therapy 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 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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 the acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below her baseline. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 

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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy, initial assessment and intervention, each 15 minutes (97802) provided February 11, 2021.

You asked the Plan to pay for medical nutrition therapy services. You say that your doctor wants you in a nutrition program as it will help with your bones, liver disease and protein in blood. You are not able to pay what they expect and it is very over-priced. The Plan denied your request. The Plan says medical nutrition therapy is not covered for the enrollee's current condition.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy, initial assessment and intervention, each 15 minutes (97802) provided February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive oral exam (D0150) cone beam computed tomography (D0367) provided November 16, 2020.
You asked the Plan to pre-approve the dental services. You say that you have enclosed a letter of explanation from your cardiologist for covering the enclosed periodontal billing. You believe the doctor's letter explains thoroughly as the need to go forward to ensure your heart health. The Plan denied your request. The Plan says the services are not covered under the Plan's benefits.
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. D0150 is covered once every 3 years. The records show this service was last provided February 20, 2020.
The health plan contract says that any service not listed is not covered. D0367 is not listed and is therefore not covered. 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. Therefore, we decided that the Plan does not have to pre-approve comprehensive oral exam (D0150) cone beam computed tomography (D0367) provided November 16, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth # 31.
You asked the Plan to pre-approve the clinical crown lengthening. You say that you need this service so that you can have a crown placed. You say that the crown was already approved. You also say that you do not understand why the services were denied. The Plan denied your request. The Plan says clinical crown lengthening 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, the requested clinical crown lengthening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth # 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E2313) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the independence in feeding and toileting indicates that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E2313) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound device.
You asked the Plan to pre-approve the ultrasound device. You say that the ultrasound device is medically necessary. The Plan denied your request. The Plan says this device is not primarily medical in nature and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an ultrasound device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on October 27, 2020 to March 11, 2021.
You asked the Plan to pay for the compression stockings. You say that please review and resubmit for payment. The Plan denied your request. The Plan says this item is not covered under the Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on October 27, 2020 to March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report (92134), the ophthalmological medical examination and evaluation (92014), and the fluorescein angiography (includes multiframe imaging) with interpretation and report (92235) provided on January 18, 2021 and February 22, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 $45 copayment for physician services provided at an in-network specialist office.

You have been asked to pay $90 ($45 copayment x 2 days) for the physician services provided at an in-network specialist office. 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 copayments for the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report (92134), the ophthalmological medical examination and evaluation (92014), and the fluorescein angiography (includes multiframe imaging) with interpretation and report (92235) provided on January 18, 2021 and February 22, 2021.