Persius/hicric huggingface dataset:
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's condition. 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 for lower extremity numbness and weakness attributed to peripheral neuropathy and for a fall. Medical conditions are stable.
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vascular surgery consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a vascular surgery consultation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a vascular surgery consultation to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied
your request. The Plan says rules for LTACH care have not been met.

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 there is no documentation provided necessitating admission to an LTACH. There is
no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there are no skilled nursing or skill therapy services required daily. The medical records do not show your condition meets a severity of illness or intensity of service criteria for 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided on
September 14, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the service was medically
necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the
enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage
member on hospice.
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 date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the emergency department visit (99284) provided on
September 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the infusion services you received at an outpatient hospital facility as well as the actual infused drugs.
You asked the Plan to waive the cost sharing for the infusion services and the infused drugs. You say that you had infusion services on November 4, 2020, and November 11, 2020. You said that you only had one prescription, but the hospital broke it into two separate services. You believe you shouldn't have to pay cost sharing for the second date of service. The Plan denied your request. The Plan says you were charged this cost sharing appropriately.
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 for services provided in an outpatient hospital facility and 20% coinsurance for Part B drugs. Records show that on this date of service, you went to an outpatient hospital facility and received infusion of Part B drugs. You have been asked to pay a $250 copayment for the infusion services and 20% coinsurance for the infused drugs. Since the allowed amount for the infusion services ($215.34) is less than your outpatient hospital copayment, you are responsible for the full allowed amount for this service. You have also been charged 20% coinsurance for the drugs themselves. This is a separate charge from the hospital services. In addition, regardless of your prescription, you had two separate services on two different dates. The hospital is permitted to charge cost sharing on a per-date-of-service basis. This means that you have been asked to pay the correct amounts 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 cost sharing for the infusion services you received at an outpatient hospital facility as well as the actual infused drugs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adult prophylaxis (D1110), periodic oral exam (D0120), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), bone graft at time of implant placement (D6104), core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided January 21, 2020, and February 5, 2020.
You asked the Plan to pay for the dental cleaning, oral exam, nitrous oxide/analgesia, tooth extraction, bone graft, core buildups and crowns. You say that your plan has not changed, and the services should be covered.
The Plan denied your request. The Plan says the dental exam and cleaning were correctly processed, and the comprehensive dental services are not covered under your 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. The Plan provided documentation that the dental exam and cleaning were provided by an out-of-network provider and were covered with 30% coinsurance. Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining 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 adult prophylaxis (D1110), periodic oral exam (D0120), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), bone graft at time of implant placement (D6104), core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided January 21, 2020, and February 5, 2020.
Your complaint about potential changes in benefits from year to year or misunderstandings about coverage 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom continuous glucose monitor reader.
You asked the Plan to pre-approve the reader. You say that this is medically necessary. The Plan denied your request. The Plan says coverage for this is limited to one every three years.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment must be considered "durable" to be covered. The expected life must be at least three years. Another monitor was received less than three years ago on August 20, 2019. Based on this information, we decided that Medicare rules for coverage of the reader have not been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom continuous glucose monitor reader.
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 need IRF care. 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 that you were admitted for surgery to remove an infected pacemaker. Medical
conditions are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 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 the MyoPro Motion G orthotic 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 this device has deluxe features that exceed medical need and replaces rather than
improves the function of the arm.
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 records indicate an evaluation for the MyoPro Motion G orthotic device occurred before the enrollee
was evaluated for the device and before the device was actually ordered by her physician. No independent
therapy notes are provided recommending the MyoPro Motion G orthotic device. In addition, current
neurology guidelines consider robotic therapy of "uncertain utility compared with dose-matched conventional
upper limb exercise therapies."
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 the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia and therapeutic drug injections.
You asked the Plan to pre-approve these services. You say that you need the services for a tooth extraction. The Plan denied your request. The Plan says the services 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep sedation/general anesthesia and therapeutic drug injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 27, 2021. She is ambulating more than 100 feet and tending to activities of daily living with activities of daily living. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network
provider on December 29, 2020.
You asked the Plan to pay for the outpatient clinic visit. You say that the attached records support the medical
necessity. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 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 outpatient clinic visit provided by an out-of-network
provider on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on March 4, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you are on a fixed income and are worried this bill will put you into debt. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, periodontal exam and comprehensive oral exam are is limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation on February 16, 2021, and your periodontal exam and comprehensive oral exam
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four excisions of hyperplastic tissue (D7970 x4).
You asked the Plan to pre-approve the excisions of hyperplastic tissue. You say that you would like to appeal
these services. The Plan denied your request. The Plan says this service is 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four
excisions of hyperplastic tissue (D7970 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and destruction of skin growth
(17110) provided on April 5, 2021, by an OON provider.
You asked the Plan to pay for an office visit and a procedure. You say that the provider's office is in-network.
You also say that you do not need a referral from your primary care physician for these services. The Plan
denied your request. The Plan says you must get care from network providers. The Plan also says that care
from an out-of-network provider is paid for cases involving emergencies, out of area urgent care and preapproved
care.
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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 office visit (99213) and destruction of skin growth (17110)
provided on April 5, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis back brace
(L0650) provided on January 5, 2021.
You asked the Plan to waive the coinsurance for a back brace. You say that the back brace did not fit properly
and after the brace was adjusted, you indicate you had trouble breathing. The Plan denied your request. The
Plan says the coinsurance you are being charged is correct.
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%
coinsurance for prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance for a back brace. The allowed amount of the claim is
$1,050.44, resulting in a coinsurance obligation of $210.09. The EOC confirms 20% is the required
coinsurance. A back brace falls within the prosthetic devices and related supplies 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 coinsurance for a lumbar-sacral orthosis back brace (L0650) provided on January 5,
2021.