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

We decided that the Plan does not have to pre-approve an inpatient hospital admission for shoulder
arthroplasty.

You asked the Plan to pre-approve inpatient hospital care. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is
correct, because this surgery can be performed as outpatient and if there are complications then consideration
for inpatient admission can be given.

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 inpatient hospital care. Our reviewer
says that inpatient hospital admission for this procedure is not medically necessary at this time. Our physician
reviewer found the records provided do not sufficiently support inpatient services for this low-risk patient and
low-risk procedure. There is no indication that the enrollee will likely require inpatient services following
surgery. A lower level of care would be 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 inpatient hospital care have not been met. Therefore, we decided that the Plan
does not have to pre-approve an inpatient hospital admission for shoulder arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urinalysis provided on November 4, 2020. 
 
You asked the Plan to pay for the urinalysis. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
urinalysis. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for a urinalysis provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular 
denture provided on December 3, 2020. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
you believe these services should be covered. The Plan denied your request. The Plan says these 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 pay for the 
complete maxillary denture and complete mandibular denture provided on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that you have been using this for over two years and would like to continue. The Plan denied your request. The Plan says that that you do not use insulin three or more times per day, use an insulin pump, have a history of hypoglycemia due to insulin use, and the prescriber does not attest that insulin dosing requires frequent adjustment.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded any medical records to substantiate their denial. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor.

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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Periodontal scaling and root planing - Four or more teeth 
per quadrant (D4341) provided October 20, 2020. 
 
You asked the Plan to pay for the Periodontal scaling and root planing. You say that the service should be 
covered. The Plan denied your request. The Plan says the service is only covered if the enrollee purchased the 
optional Platinum Dental Rider benefit. The enrollee has not chosen to purchase this extra dental benefit. The 
service is not included in the list of covered services under enrollee's dental benefits. 
 
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 
Periodontal scaling and root planing - Four or more teeth per quadrant (D4341) provided October 20, 2020.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and a diabetic foot 
ulcer. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 
 
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 insertion of a CardioMEMS device.

You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due to worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that CardioMEMS is helpful for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until October 15, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on January 24, 2019.
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 an extended amount of antibiotics is
needed to be treated with Hyperbaric oxygen therapy. The Plan denied your request. The Plan says the
enrollee's needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that the enrollee was admitted to the acute hospital for the treatment of a chronic right hip
Periprosthetic infection. The enrollee is receiving appropriate care at the present acute care facility. 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.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for a lumbar laminectomy procedure.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee does not have a complex medical history.

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 inpatient services. Our physician reviewer found that the enrollee is medically stable. The planned procedures listed under the approved codes are not on the Centers for Medicare and Medicaid Services Inpatient Only List. The records do not show that the enrollee has a condition that would warrant inpatient care during the approved surgery. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for a lumbar laminectomy procedure.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. You do not have 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 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. 
 
Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone-acetaminophen.

You asked the Plan to pre-approve the requested drug. You say that the enrollee has been stable on this
medication for more than a year. The Plan denied your request. The Plan says this drug to be taken at home is
not covered under the Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self administered
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 Oxycodone-acetaminophen.

Benefits for the requested drug 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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for metabolic encephalopathy, 
weakness and trouble breathing. He was discharged to skilled nursing facility then to home, where he currently 
resides. He has ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 
 
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 waive the copayment for the endoscopy provided on October 1, 2020 
and October 9, 2020. 
 
You asked the Plan to waive the copayment for the endoscopies. You say that you were informed the device 
malfunctioned and the medical center should assume responsibility. The Plan denied your request. The Plan 
says the copayments 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 Medicare-covered outpatient surgery. 
 
You have been asked to pay a $295 copayment for each endoscopy. The total amount you owe is $590 
($295/endoscopy x 2 endoscopies = $590). The endoscopies fall within the "Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the endoscopy provided on October 1, 2020 and October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided 
participating providers on March 18, 2020, to April 7, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were continually 
inpatient until April 7, 2020. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
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 $285 
copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $285 copayment per day for days 1-7. There is a $0 copayment for additional 
days for an inpatient hospital stay.  
 
Dates of Service Hospital Days Total Amount 
March 18, 2020 - March 25, 2020 Doctor's Hospital Augusta 7 $1,995 
March 25, 2020 - March 31, 2020 AU Medical Center 6 $1,710 
April 1, 2020 ? April 7, 2020 Encompass Health Walton Rehab Hospital 6 $1,710 
 
Total Amount Being Asked to Pay: $5,415 ($1,995 + $1,710 + $1,710 = $5,415) 
 
The EOC says that your inpatient benefits will begin on day one each time you are admitted within or to a 
specific facility type. A transfer within or to a facility including inpatient rehabilitation facilities, long term 
acute care (LTAC) facilities, inpatient acute care facilities, and inpatient psychiatric facilities, is considered a 
new admission. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided by participating 
providers on March 18, 2020 to April 7, 2020. An inpatient hospital stay falls within the inpatient hospital 
care/in-network benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital 
stay provided by participating providers on March 18, 2020 to April 7, 2020.