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

We decided that the Plan does not have to pre-approve continued admission to an inpatient mental health
facility.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there are other services that may be available to you.

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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not
meet the criteria for continued treatment, as you were not shown to be a danger to yourself or others. You were
not showing any auditory or visual hallucinations. You were cooperative and compliant with treatment, while
not showing any acute threats to safety. The health plan's denial of continued inpatient psychiatric services is
appropriate.

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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued admission to an inpatient mental health facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone visit you had with your pulmonologist on October 27, 2020.
You asked the Plan to waive the copayment for the telephone visit. You say that you shouldn't have to pay a copayment for this five-minute conversation. The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the telephone visit. The telephone visit falls within the specialist visits benefit category because your Evidence of Coverage explicitly states that the copayment applies to brief virtual (i.e., telephone) 5-10 minute check-ins with your doctor. 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 telephone visit you had with your pulmonologist on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested services are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for acute inpatient hospital care have not been met.

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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found that the enrollee is being treated for primary osteoarthritis of the left shoulder and will be receiving a shoulder arthroplasty. The planned procedure is supported as an outpatient procedure in recent published peer-reviewed literature. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of the request for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140).

You asked the Plan to pay for a limited oral evaluation. You say that you were told that the provider was in-network. The Plan denied your request. The Plan says the service is not a covered benefit.

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 a limited oral evaluation (D0140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to an inpatient psychiatric facility.

You asked the Plan to pre-approve the admission. You say that this is needed due to concerns for self-harm.
The Plan denied your request. The Plan says a lower level of care, such as partial hospitalization, is needed.

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 the admission. Our reviewer says that
the requested services are not medically reasonable or necessary. Our physician reviewer found you do not
meet the criteria for continued treatment at this time, as you are not shown to be a danger to yourself or others.
You were not showing any auditory or visual hallucinations. You are cooperative and compliant with treatment
while not showing any 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued admission to an inpatient psychiatric facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392).

You asked the Plan to pay for the resin-based composite. You say that this service should be covered as dental care is important. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's mandatory supplemental dental benefit.

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 resin-based composite (D2392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Astigmatism correcting function of intraocular lens and multifocal IOL (V2787, A9270) provided on October 5, 2020.
You asked the Plan to pay for Astigmatism correcting function of intraocular lens and multifocal IOL. You say that you do not understand why this service would not be covered. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for Astigmatism correcting function of intraocular lens and multifocal IOL (V2787, A9270) provided on October 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 17, 2019, to September 15, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee elected Hospice on August 17, 2019. The Plan also says that during this time period, skilled nursing services when necessary would be covered under the hospice, not Medicare Part C benefit.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 17, 2019, to September 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on October 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an echocardiography. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained by a participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an echocardiography provided on October 13, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and computerized ophthalmic diagnostic imaging (92134) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit and diagnostic imaging. You say that you did not know this provider was out of network and you cannot afford this bill. The Plan denied your request. The Plan says they do not cover out-of-network care except in limited circumstances. The care provided was not urgent or emergent, nor was it pre-approved. No referral was submitted by a Plan-contracted provider for review.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and computerized ophthalmic diagnostic imaging (92134) 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 the implant/abutment supported fixed denture for edentulous
arch - maxillary.
You asked the Plan to pay for the implant. You say that you had a dental emergency that needed to be handled.
The Plan denied your request. The Plan says the requested service is not covered under your dental benefit.
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
implant/abutment supported fixed denture for edentulous arch - maxillary.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the staff told you that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit.

You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit.
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 is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for IRF care have 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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient was admitted to the hospital for sepsis and urinary tract infection. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).

You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is urgently needed. The Plan denied your request. The Plan says rules for a portable oxygen concentrator are not met because the available documentation does not establish the inability to use the existing portable oxygen tanks.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.

The file shows that you have a stationary oxygen concentrator and portable oxygen tanks. A stationary oxygen concentrator and portable oxygen tanks serve the same purpose as a portable oxygen concentrator. There is no objective evidence presented to support that the current setup is unable to meet your needs within the home. The requested item may provide improved ease of use outside the home; however, use outside the home is not a Medicare-covered indication. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).

Your complaint about the Plan not effectively communicating with your 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 pre-approve a crown (D2740) for tooth #7 and core buildup, including any pins when required (D2950) for tooth #7.

You asked the Plan to pre-approve the crown and core buildup. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services exceed 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, crown (D2740) and core buildup, including any pins when required (D2950) are each limited to one procedure per tooth every five plan years. The record shows that you received approval for a crown (D2740) for tooth #7 and approval for a core buildup, including any pins when required (D2950) for tooth #7 and your crown (D2740) and core buildup, including any pins when required (D2950) benefits for tooth #7 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #7 and core buildup, including any pins when required (D2950) for tooth #7.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 2, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says this service was rendered by an OON provider, and the enrollee was referred by a non-participating nursing facility. The Plan also says that the enrollee's primary care physician did not refer for 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 2, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the cervical
spine (72141).

You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the
requested MRI is not medically necessary. Our physician reviewer found there are no physical exam
abnormalities noted on exam. X-rays of the cervical spine demonstrated mild disc space narrowing. The has
been no course of conservative treatment such as medication or physical therapy completed.

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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the shingles vaccine administration provided on October 5, 2020.
You asked the Plan to reimburse you for the shingles vaccine administration (90471). You say that the Plan should reimburse you. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine administration (90471). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine administration (90471). Therefore, we decided that the Plan does not have to reimburse you for the shingles vaccine administration provided on October 5, 2020.
Benefits for the shingles vaccine administration (90471) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.