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

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not need more than 6 hours of nursing each day, complex medicine, or a machine to help her breathe.
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 is currently undergoing treatment at an acute care hospital (ACH) for pneumonia in the setting of end-stage HIV/AIDS. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. The enrollee is noted to be medically non-compliant and appropriate for Hospice. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections for the enrollee.
You asked the Plan to pre-approve Botox. You say that the enrollee would like to try 150 units before moving on to surgery options. The Plan denied your request. The Plan says 150 units exceeds the FDA-approved maximum dose for overactive bladder control.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox. Our physician reviewer found that the enrollee has an overactive bladder. She has been receiving Botox injections 100 units per injection. An increase in Botox dose to 150 units requested. The provided medical records do not support that the requested dosage is medically reasonable and necessary for the enrollee. The provided medical records do not support that the requested dosage is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the additional initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the odontoplasty (D9971 x 2), the emergency treatment of dental pain (D9110), and the removal of jaw bone (D7471) provided from August 20, 2019 to September 30, 2019.
You asked the Plan to reimburse you for the 2 additional periapical x-rays, the 2 odontoplasty, the removal of jaw bone, and the emergency pain treatment. You say that the services you received should have been billed under your medical plan. You say that the services you received were medically necessary as you are a diabetic. The Plan denied your request. The Plan says odontoplasty, removal of jaw bone, and emergency pain treatment are not listed as covered service. The Plan also says that the frequency limit for periapical x-rays 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the additional initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the odontoplasty (D9971 x 2), the emergency treatment of dental pain (D9110), and the removal of jaw bone (D7471) provided from August 20, 2019 to September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is not stable, and is not tolerating pressure support trials with adequate respiratory effort.
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 is currently undergoing treatment at an acute care hospital (ACH), having been admitted after missing hemodialysis for a month. The enrollee apparently required intubation/ventilation and eventually received a tracheotomy. She remains on a ventilator and is noted to have a poor overall prognosis. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve Evenity. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Evenity. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has osteoporosis. Evenity is not FDA-approved or medically indicated for males - it only has approval for postmenopausal women. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
You asked the Plan to pre-approve the seat lift mechanism. You say that you need a power lift recliner to help
you to stand up. The Plan denied your request. The Plan says there is no evidence that you can walk, you are
incapable of standing up from a regular chair, or the seat lift mechanism is part of your physician's course of
treatment.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We looked at the file and Medicare rules. Criteria have not been met. Based on this information, we decided
that Medicare rules for coverage of the seat lift mechanism have not been met. Therefore, we decided that the
Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided from August 14, 2019 to September 16, 2019.
You asked the Plan to pay for the physician services. You say that the physician services should be covered and paid in network. 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 member'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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided from August 14, 2019 to September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on September 19, 2019.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you were told to pay the bill. You say the reimbursement should be sent to you. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered Part B drug obtained in an in-network outpatient setting. You have been asked to pay a total of $117.13 which is 20% of the total allowed amounts for the Part B injections. The total allowed amounts is $585.65. ($585.65 x 20% = $117.13). The Part B injections fall within the "Medicare Part B prescription drugs" 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 the Part B injections provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve allergy/immunology treatment to be provided at the in-network benefit level.
You asked the Plan to pre-approve specialist services. You say that you need to see this provider to discuss routine treatment for your condition, and there is no one closer in your area that can treat you. The Plan denied your request. The Plan says the denial of authorization for coverage at the in-network benefit level is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist. The Plan says that you may choose to receive services from the doctor at the out-of-network benefit level, which is $75 copayment per visit.
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 $75 copayment for each out-of-network specialist office visit. You may also be responsible for out-of-network cost-sharing for other items or services provided to you at visits, for example diagnostic testing. You may choose to receive services from the doctor at the Plan's out-of-network benefit level, which is $75 copayment per specialist office visit. Specialist services fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. 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 pre-approve allergy/immunology treatment to be provided at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection for the enrollee.
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 services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and sacroiliitis. She states she has had physical therapy and a home exercise program, but there is no documentation of the results. She has not had an adequate documented trial of conservative therapy. The requested SI joint injection is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge day management provided on September 19, 2019.
You asked the Plan to pay for the nursing facility discharge day management. You say that the enrollee was discharged to her home with hospice care. You also say that the enrollee was enrolled in hospice at the providers request. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 nursing facility discharge day management provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral, complete series x-ray provided on March 26,
2019.

You asked the Plan to pay for the intraoral, complete series x-ray. You say that you thought you x-rays would
be covered when you switched plans. You say that you did not exceed your benefit. The Plan denied your
request. The Plan says panorex x-rays or complete series rays are only covered one series every three years.
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 Plan also has a maximum benefit
amount of 1 panorex x-ray or complete series x-ray every 3 years. The requested service is not covered because
the Plan paid for a complete series x-ray on March 22, 2019, which exhausted your benefit. Therefore, we
decided that the Plan does not have to pay for the intraoral, complete series x-ray provided on March 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on July 17, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on July 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a cranial nerve neurostimulator.
You asked the Plan to pre-approve implantation of the Inspire Upper Airway Stimulation System. You say that a CPAP has failed to work for you and your physician says you meet all the clinical criteria for this procedure. The Plan denied your request. The Plan says neither Medicare nor the Plan cover a hypoglossal nerve stimulator.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Implantation of a hypoglossal nerve stimulator for treatment of OSA is considered experimental/investigational, and therefore not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of implantation of the Inspire Upper Airway Stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a cranial nerve neurostimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approve IRF care. You say that with a more aggressive approach, the enrollee will be able to get better faster.The Plan denied your request. The Plan says you do not have any complex therapy needs.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the requestto pre-approve IRF care. Our physician reviewer found that you are at minimal assist for transfers and sit-to-stand. You are at a contact guard assist level for ambulation using a rolling walker. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for Ambulance services (A0425, A0427) provided October 13, 2019.You asked the Plan to waive the deductible forthe Ambulance services. You say that the correct copayment should be $270.The Plan denied your request. The Plan says the deductible had not been fully paid at the time of services.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible and then a $270 copayment for ambulance services.The item or service you asked the Plan to waive the deductible for falls within the benefit category Ambulance transport. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time the Ambulance services was received on October 13, 2019.Therefore, we decided that the Plan does not have to waive the deductible forAmbulance services (A0425, A0427) provided October 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray provided on September 4, 2019.
You asked the Plan to waive the copayment for the hip x-ray. You say that you could not get the x-ray at your primary provider. You say that the x-ray should be covered under the Plan. The Plan denied your request. The Plan says the copayment 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 $40 copayment for basic radiological services at an in-network specialist's office, non-preferred urgent care center or free standing radiological facility. You have been asked to pay a $40 copayment for the hip x-ray. The hip x-ray falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the hip x-ray provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost forthe methylprednisolone injection. We decided that the Plan does not have to waive the copaymentforthe tendon sheath injection. You asked the Plan to waive the cost share forthe tendonsheathinjection and methylprednisolone injection. You say that your copayment for a specialist is $25.The Plan says that the cost share applied correctly.We decided that the Planhas to reducethe cost forthe methylprednisolone injection. 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 10% of the cost per prescription or refill.
The Plan says that you must pay $13.10 for the methylprednisolone injection. Based on the Plan contract, however, you cannot be asked to pay more than $1.31. The allowed amount of the methylprednisolone injectionis $13.10 (10% x $13.10 = $1.31). Therefore, we decided that the Plan has to reducethe cost forthe methylprednisolone injection. We also decided that the Plandoes not have to waive the copaymentforthe tendon sheath injection.Your contract with the Plan clearly says that you must pay a $25 copaymentfor each specialist visit for Medicare-covered benefits.Covered services include medically-necessary medical care or surgery services furnished in a physician's office.Therefore, we decided that the Plan does not have to waive the copaymentforthe tendon sheath injection.