Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued respiratory management, IV antibiotics, rehab therapies, and daily physician visits. The Plan denied your request. The Plan says the enrollee can receive care in the current setting.
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 physician reviewer found 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 therapy with oxygen supplementation and pulmonary toilet, surveillance laboratory studies, chest tube care, tube feedings, 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from August 3, 2019 to August 4, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges. 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 a $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER 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 ER visit provided from August 3, 2019 to August 4, 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's ongoing medical care warrants this level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the enrollee does not require close physician monitoring, or an intensive multi-disciplinary team approach to therapy.
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's current level of function is refusing to participate in physical and occupational (PT and OT) due to exhaustion and not feeling well, supine to sit with supervision, sit to stand with contact guard assist, minimal assist with balance, taking 6 steps with a rolling walker with minimal/contact guard assist, wheelchair propulsion of 200 feet with contact guard/supervision. Prosthetic training has not been initiated. The enrollee is currently medically stable. There is no evidence of medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and 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 to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevitreolysis (67031).You asked the Plan to pre-approvevitreolysis. You say that you have floaters that interfere with your vision.The Plan denied your request. The Plan says this is not covered for your condition.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 vitreolysis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found although the you have peripheral vascular disease (PVD)in both eyes, this finding is unlikely to significantly impact your visual acuity and functioning.  YAG vitreolysis is not the standard of care for PVD and has been used in certain instances for patients who are severely affected by floaters. In this case, as you have very poor visual acuity from age-related macular degeneration, there is more risk than benefit in performing this procedure for floaters. Therefore it is neither medically reasonable or necessary to perform a YAG vitreolysis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vitreolysis have not been met.Therefore, we decided that the Plan does not have to pre-approvevitreolysis (67031).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory surgical boot (L3260).
You asked the Plan to pay for ambulatory surgical boot. You say that you are requesting an appeal for the boot due to having a fracture in his left foot and it is a medical need and have lots of swelling. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulatory surgical boot have not been met. Therefore, we decided that the Plan does not have to pay for ambulatory surgical boot (L3260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device (L8702).  You asked the Plan to pre-approve powered upper extremity range of motion assist device. You say that you request reconsideration of the denial and permit coverage for this device. The Plan denied your request. The Plan says this provider is out of network and the myoelectric arm is investigation, exceeds your needs and exceeds general standards of medical practice.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of powered upper extremity range of motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device (L8702).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (PT) (97110, 97112, 97116) provided on July 15, 2019 to August 8, 2019 by out of network provider.  You asked the Plan to pay for PT. You say that you are appealing the denial of no prior authorization for out of network services. The Plan denied your request. The Plan says it is important to know which providers are part of the network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers.
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 physical therapy (PT) (97110, 97112, 97116) provided on July 15, 2019 to August 8, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 26, 2019 to August 1, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the charges. 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 a $250 copayment per day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from July 26, 2019 to August 1, 2019. Therefore, you are responsible to pay a $250 copayment for days 1-6 (July 26, 2019 to July 31, 2019). $250 (copayment) x 6 (inpatient days) = $1,500.00. You have been asked to pay the total copayment amount of $1,500.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay provided from July 26, 2019 to August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a basic metabolic panel (80048) and a lipid panel (80061) provided on September 11, 2019.
You asked the Plan to pay for a basic metabolic panel and a lipid panel. You say that these services were medically necessary. The Plan denied your request. The Plan says these were non-covered screening services.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a basic metabolic panel and a lipid panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a basic metabolic panel (80048) and a lipid panel (80061) provided on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 8, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you have never had to pay for laboratory services in the past. 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 a $20 copayment for laboratory services provided in a specialist's office. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall within the laboratory 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 laboratory services provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need inserts for your foot condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medication Avastin (J9035).You asked the Plan to pre-approvethis medication. You say that Avastin is medically necessary for the treatment of a vitreous hemorrhage of the enrollee's right eye.The Plan denied your request. The Plan says the enrollee does not meet the criteria for Avastin. Therefore,the medication is not covered by Medicare or the member's health plan.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 this medication. Our reviewer says that the enrollee does not meet criteria for coverageof Avastin. Our physician reviewer found the documentation does not support that the requested drug is safe and effective, and reasonable and necessary for the treatment 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 this medication have not been met.Therefore, we decided that the Plan does not have to pre-approvethe medication Avastin (J9035).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the cost sharing amount forthe implant supported retainer for a fixed partial denture (D6075 x 3), and the surgical placement of mini implant (D6013 x 3) provided from September10, 2019 to September 12, 2019.You asked the Plan to pay the cost sharing amount forthe implant supported retainer for a fixed partial denture, and the surgical placement of mini implant. You say that the Evidence of Coverage and the dental brochure do not reference that implants would not be covered as restorative service.The Plan denied your request. The Plan says dental implants are not a covered service. The Plan also says that if the services are not listed they are not covered.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, dental implants are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the cost sharing amount forthe implant supported retainer for a fixed partial denture (D6075 x 3), and the surgical placement of mini implant (D6013 x 3) provided from September 10, 2019 to September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysan intensive rehabilitation program 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 your medical conditions appear stable. There are no complex wound care needs. You do not require medical oversight of her condition at an acute hospital level of care. There is a primary rehabilitation diagnosis of debility which does not support the medical necessity of acute level rehabilitation. You are limited by debility and the severity of your comorbid medical conditions. You are unable to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. You are unable to participate in an intensive rehabilitation therapy program and there is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a lesser level of 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for alcohol abuse treatment provided to the enrollee from July 22, 2019 through July 26, 2019, by an out-of-network provider.You asked the Plan to pay foralcohol abuse treatment. You say that the stay was medically necessary.The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 carefrom 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 foralcohol abuse treatment provided to the enrollee from July 22, 2019 through July 26, 2019, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF provided from May 23, 2019 through May 30, 2019.You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNFcare from May 9, 2019 through May 23, 2019. You areasked to pay a $100 copayment per day for days 21-100 of SNF care. 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment forSNF provided from May 23, 2019 through May 30, 2019
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-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, 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 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical placement of implant body: endostealimplant, teeth #21 and #28 (D6010) provided on October 2, 2019.You asked the Plan to pay forthe dental services. You say that the service is necessary.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. Implants on posterior teeth are not a covered benefit.Therefore, we decided that the Plan does not have to pay forsurgical placement of implant body: endosteal implant, teeth #21 and #28 (D6010) provided on October 2, 2019