Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 23, 2019.You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up visit for a surgery that was done on August 26, 2019.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.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 specialist office visit provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate fortheadditional periapical x-ray (D0230) provided on April 24, 2019.You asked the Plan to pay the in network rate forthe additional periapical x-ray. You say that you found the provider office listed on the Plan website.The Plandenied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare 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 frequency limit for periapical x-rays has been exceeded. The record shows that the Plan paid for1 periapical x-ray that you received on April 24, 2019.Therefore, we decided that the Plan does not have to pay the in network rate forthe additional periapical x-ray (D0230) provided on April 24, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond March 1, 2020.You asked the Plan to pre-approvethe continued SNF care. You say that you believe that ongoing care is necessary in this case.The Plan denied your request. The Plan says the enrollee no longer needs daily skilled services.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 todetermine if the Plan was correct in denying the request to pre-approve the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment beyond the last covered day. The patient does not have new enteral feedings, complex wound care or otherSNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care beyond March 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methocarbamol 750mg tablet (J8499).
You asked the Plan to pre-approve Methocarbamol 750mg tablet. You say that the requested medication is
necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not
include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been
met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methocarbamol 750mg
tablet (J8499).
Benefits for Methocarbamol 750mg tablet may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment for these services.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 foran office visit provided on September 30, 2019 by an out of network (OON) provider.
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), having been admitted with sepsis. He was found to have endocarditis, for which he is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says IRF care 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 that the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a skilled nursing facility. Additionally, the member requires a mostly moderate to maximal level of assistance for functional transfers and activities of daily living; therefore, a less intensive, longer duration of therapy will allow for measurable gains within a predicted period of 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay for progressive lenses (V2781) and miscellaneous vision item, edge polish (V2799) provided July 27, 2019.You asked the Plan to pay forthe vision services. You say that you have paid $199.99 for your lenses. While you realize that tinting andtransitions are not covered but you believe that some correct should be allowed.The Plan denied your request. The Plan says progressive lenses and edge polish are upgraded items that are excluded. The plan has approved reimbursement of $149.99 for standard frames and standard lenses.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when coverage is limited to 1 pair of standard lenses and frames.We looked at the file and the Plan's rules. The plan has approved reimbursement of $149.99 for the cost of standard frames and standard lenses. The progressive lenses and edge polish upgrades are excluded. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) and miscellaneous vision item, edge polish (V2799) provided July 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital services provided April 23, 2019 to May 31, 2019.You asked the Plan to pay forthe inpatient hospital services.. You say that the records provided should support the services in dispute.The Plan denied your request. The Plan says the claim does not meet pre-admission bundling requirements.The Planmust follow Medicare rules. Medicare rules say that providers can bill preadmission services on their inpatient claim as long as they are within three days of Admit Date.  Any services provided more than three days prior to inpatient admission on 5/28 cannot be included on the inpatient claim. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services. have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital services provided April 23, 2019 to May 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a portable oxygen concentrator.You asked the Planto pre-approvethe portable oxygen concentrator. You say that the tanks that you have been given are too heavy for use outside of the home. A portable concentrator is needed for this.The Plandenied your request. The Plansaysthis request is for improved usability outside the home. Medicare does not cover equipment upgrades that are needed solely for use outside of the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plandoes not haveto pre-approvea portable oxygen concentrator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT Scan (G0297).You asked the Plan to pre-approve the low dose CT Scan. You say that the lowdose CT Scan is medically necessary because the member has been smoking for 30 years and is experiencing shortness of breath. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria due to their age is less than 55 years.The Plan must follow Medicare rules. Medicare rules say that for Medicare to cover lung cancer screening with LDCT, beneficiaries must be between the ages of 55 and 77.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the low dose CT Scan have not been met. Specifically, the record indicates that the member is less than 55 years old. Therefore, we decided that the Plan does not have to pre-approve a low dose CT Scan (G0297).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home use and application of desensitizing medicament provided on October 16, 2019.You asked the Plan to pay for the drugs or medicaments and application of desensitizing medicament. You say that you are eligible to be reimbursed because this seems to be a coding error.The Plan denied your request. The Plan says these services are not covered 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.Therefore, we decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home use and application of desensitizing medicament provided on October 16, 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 for enrollee.You asked the Plan to pre-approve IRF care. 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. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on Decmeber 26, 2019 and diagnosed with a left stroke. He was discharged home with home health services and was dependent for function and used a Hoyer lift. He currently requires minimal assist with walking 150 feet with a rolling walker and moderate assist with bathing, toileting, and lower body dressing. His condition is stable and does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services for enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites, core buildup, including any pins when required, and two endodontic therapy services provided on September 26, 2019.
You asked the Plan to pay for the resin-based composites, core buildup, and endodontic therapy services. You say that the medications you take have led to dental problems. You also say that you are on a limited income. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. Therefore, we decided that the Plan does not have to pay for the two resin-based composites, core buildup, including any pins when required, and two endodontic therapy services provided on September 26, 2019.
Your complaint about the unprofessionalism and rudeness of this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on November 6, 2019.You asked the Plan to pay for the intraoral periapical x-rays. You say that this provider told you that they accepted your insurance. You also say that you were not told that the x-rays would not be covered.The Plan denied your request. The Plan says these procedures are not covered benefits under your dental 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. The dental plan only covers bitewing x-rays and panoramic or full mouth x-rays.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on November 6, 2019.Your complaint about being misled by the Plan and provideris 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 enrollee would receive the best care in the LTACH setting. The Plan denied your request. The Plan says the enrollee does not require continued acute hospital 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 the patient is currently undergoing treatment at an ACH. He was admitted with weakness and subsequently suffered a cardiac arrest. The enrollee was intubated/ventilated and subsequently received a tracheotomy. He has been weaned from the ventilator. He is noted to have an overall poor, long-term prognosis. 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 LTC 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: 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 care would beneficial in allowing the enrollee to regain strength.The Plan denied your request. The Plan says the enrollee has no acute medical issues which require frequent physician supervision.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 enrollee was recently diagnosed with squamous cell carcinoma of the salivary glands with metastasis to the lungs and bone. 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. The documentation does not reveal that the patient requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient 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 IRFcare have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.