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

We decided that the Plan does not have to pay for the acute inpatient hospital care.

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 services were not medically necessary.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) with recurrent chest and abdominal pain. The initial workup in the ED revealed a normal electrocardiogram (EKG) and troponin, as well as an unremarkable computed tomography (CT) scan of the chest and abdomen. The admitting physician did not document an expectation that the enrollee's stay would span two midnights. Furthermore, based upon the documentation of findings and history at the time of presentation, a reasonable expectation of a two midnight stay did not exist.

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 pay for the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is no documentation that the enrollee's most recent medial branch block helped improve pain by at least 80%.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has chronic low back pain. She is taking Tramadol for pain. She had a first set of diagnostic bilateral MBB, which had 70% pain relief and increased mobility for 2-3 days. The enrollee did not achieve the 80% level of pain relief required. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a medial branch block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care.

You asked the Plan to waive the copayment for the inpatient care. You say that you were told you did not have to pay a copayment for all services, and this cost is too expensive. The Plan denied your request. The Plan says inpatient hospital care requires a $295 copayment for each of the first six days of a single hospital admission. This copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for each of the first six days of an inpatient hospital stay.

You have been asked to pay a $1,180 copayment for four days of inpatient care ($295 x 4 days = $1,180). 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 inpatient care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient mental health care. Our physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question, forward and could have been treated in a lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing only occasional behaviors or aggression which were controlled, being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of tissue, and subsequent nursing facility care provided by an out of network (OON) provider.

You asked the Plan to pay for the wound care. You say that the services were rendered to the enrollee prior to obtaining prior authorization to avoid delay in care. You also say that the enrollee was referred for the services by their primary care provider (PCP). The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee.

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 record shows that the referring provider in this case was not the enrollee's PCP, nor are they a network provider. 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 debridement of tissue, and subsequent nursing facility care provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is only covered when performed as routine and billed with a routine diagnosis.

The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction. 

The services you asked the Plan to pay for is considered not routine and refraction. Therefore, we decided that the Plan does not have to pay for eye refraction services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 they are currently receiving care. 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0150, D0415, D0367).

You asked the Plan to pay for the services. You say that you were in serious need for dental work. The Plan denied your request. The Plan says the claim was processed correctly.

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 twice per year. The same services were previously received. Additionally, D0415 and D0367 are not listed as covered benefits in the plan contract material. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services (D0150, D0415, D0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, extraction, comprehensive oral evaluation, and prophylaxis provided by an OON provider.

You asked the Plan to pay for the bitewings, extraction, comprehensive oral evaluation, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you must use network providers to get your medical care and 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 covered when they are received OON. The record shows that during your phone calls with the Plan you were provided with in network providers available in your area to contact and schedule an appointment. You were advised that a pre-authorization would be required to see an OON provider. Therefore, we decided that the Plan does not have to pay for the bitewings, extraction, comprehensive oral evaluation, and prophylaxis provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) and wound debridement (11042) provided by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility and wound care services. You say that there were no in-network providers available to perform these medically necessary services. The Plan denied your request. The Plan says they only cover out-of-network care in limited circumstances. These services were not pre-approved and there was no referral provided by the enrollee's primary care provider. This care could have been provided in-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 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. Medical records indicate the services were provided as a follow-up to previous care provided in another facility. 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 nursing facility care (99308) and wound debridement (11042) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TDAP vaccine and its administration fee.

You asked the Plan to pay for the TDAP vaccine. You say that the requested vaccine should be covered because you received the vaccine due to an injury. The Plan denied your request. The Plan says this vaccine is not eligible for coverage under Original Medicare and the request for payment should be submitted under Medicare Part D.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. Therefore, we decided that the Plan does not have to pay for the TDAP vaccine and its administration fee.

Benefits for the TDAP vaccine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you are at risk of fall and further hospitalization if not released to the proper level of care. The Plan denied your request. The Plan says rules for SNF care have not been met because you only need custodial care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a push rim power assist device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that this is needed in order to use a manual wheelchair in the home.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the push-rim activated power assist device (E0986) for a manual wheelchair is not medically necessary as the documentation does not support that the patient enrollee the power assist to use a manual wheelchair to participate in MRADLs in the home.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a push rim power assist device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650).

You asked the Plan to pay for the addition of a tooth to an existing partial denture. You say that you have 2 sets of dentures, lost a tooth, and needed the tooth replaced on both sets of dentures. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, add tooth to existing partial denture (D5650) is limited to one per partial denture per plan year. The record shows that you received an addition of a tooth to an existing partial denture (D5650) and your addition of a tooth to an existing partial denture (D5650) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for urgently needed services.

You asked the Plan to waive the copayments for urgently needed services. You say that you thought that all copayments were waived due to COVID-19. 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 urgently needed services.

You received urgently needed services. Therefore, you are responsible to pay the $20 copayment.

You received urgently needed services. Therefore, you are responsible to pay the $20 copayment.

The total amount you owe is: $40.

You have been asked to pay the total copayment amount of $40 for urgently needed services. Urgently needed services fall within the urgently needed 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 copayments for urgently needed services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a shoulder arthroscopy.

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 that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 medically necessary. Our physician reviewer found the records show that you have complaints of shoulder pain. There is a loss of range of motion in your shoulder, resulting in decreased functional capacity. Orthopedic testing revealed positive impingement test results. You have tried and failed reasonable non-surgical management, including extensive physical therapy and injections. Diagnostic testing revealed tendinitis and degenerative joint disease. There is no evidence of other pathological conditions that could be a cause of the pain. The requested shoulder arthroscopy is the standard of care for your condition and is reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a shoulder arthroscopy.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital after a fall with resulting hip fracture. The physical therapy note states she needs modified assist with sitting up and lying down, standing, and is unable to walk at this time. The occupational therapy note states she needs modified assist for rolling, sitting up, and maximal assist of two to take one step. She does not does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary. 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.