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

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says you can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our reviewer says that the requested services are not medically necessary at this time. Our physician reviewer found based on the records provided it is not expected you would improve in a reasonable period of time as you did not have dangerousness to yourself or others, auditory or visual hallucinations, or delusions and you were not showing any behavioral issues. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower 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 inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need these for foot longitude and metatarsal support. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need the requested bath chair because you have weakness in your legs. You stated that you need something to hold onto while you are showering in case you start to fall. You say that you suffer from gait instability and the chair is a necessity for you. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a negative pressure wound therapy pump and supplies.
You asked the Plan to pre-approve these services. You say that your physician wants to use this during your knee surgery. The Plan denied your request. The Plan says that this is not covered for your condition.
The Plan must follow Medicare rules. Medicare rules say that a negative pressure wound therapy pump and supplies are only covered when there is an ulcer or wound. We looked at the file and Medicare rules. The file does not indicate you have an ulcer or wound. 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 negative pressure wound therapy pump and supplies.
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 rehab. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found you were admitted to the hospital on June 24, 2020 with fractures after a fall. You are now medically stable and need some assistance with activities of daily living and transfers. You do not have any complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 19, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this office visit should be included as a part of the heart catheterization placement procedure. 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 a $40 copayment for each in-network Medicare-covered visit with a specialist. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 specialist office visit provided on March 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on January 31, 2020.You asked the Plan to waive the copayment forthe ambulance transport. You say that you don't agree that you needed an ambulance to transport you to the hospital. You say that this was not an emergency.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 $225 copayment for each Medicare-covered one-way trip by ground transportation.You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that youwere transported by ambulance to the hospital. 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, wedecided that the Plan does not have to waive the copayment forthe ambulance transport provided on January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe request for this admission cannot be approved at this time.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not have complex daily wound care or other ongoing SNF level SN need.His functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not require skillednursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on 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 the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ALS routine disposable supplies (A0398) provided February 18, 2020.You asked the Plan to pay forthe ambulance services. You say that you complained of weakness, chest pressure and then fainted. An ambulance crew, you believe, was in the same place and they took you to the hospital with low blood pressure and irregular heartbeat.The Plan denied your request. The Plan says payment for these items is included in the payment for the ambulance transport. Medicare does not allow for separate billing of these services and supplies.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.  The rules say that oxygen and other items and services provided as part of the transport are included in the fee schedule base payment rate and are not separately payableWe looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe ALS routine disposable supplies (A0398) provided February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam provided on February 5, 2020.You asked the Plan to waive the copayment forthe eye exam. You say that checking for glaucoma is not a medical diagnosis. You say that this was a routine eye exam.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 $45 copayment for a medical eye exam.You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that you were evaluated for cataracts, which is considered a medical eye exam. 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 forthe eye exam provided on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the extensive arthroscopy services provided on November 15, 2019.
You asked the Plan to pay for the provided services. You say that surgical debridement is clearly outlined in the report. The Plan denied your request. The Plan says the code is not substantiated by the clinical documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 29823 is Arthroscopy, shoulder, surgical; debridement, extensive. We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the provided services. Our coding reviewer found that the operative report does not support this code. The report does not indicate that extensive debridement was performed on shoulder. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the provided services have not been met. Therefore, we decided that the Plan does not have to pay for the extensive arthroscopy services provided on November 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from January 5, 2020 to January 13, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you were not informed you would have to pay out of pocket for these services. The Plan denied your request. The Plan says that the claim processed 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 $170.50 copayment for days 21 through 100 of SNF care. You have been asked to pay a $1,534.50 copayment for the SNF services. The file indicates you were in a SNF for a total of 29 days. The SNF services falls within the days 21 through 100 of SNF care 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 skilled nursing facility (SNF) services provided from January 5, 2020 to January 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea whole body bone scan.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.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 ongoing right hip pain and was treated for possible bursitis in 2017. An in-office pelvic x-ray showed mild degenerative changes. A recent physical examination was benign. Multiple prior x-rays are reported to have been negative. The documentation does not support that the requested test is medically necessary or reasonable.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-approvea whole body bone scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus palatinus (D7472).
You asked the Plan to pre-approve the dental services. You say that you are experiencing extreme pain from the bone protrusion on the roof your mouth. It is causing damage to your top denture and you have trouble eating and swallowing. The Plan denied your request. The Plan says this service is not covered under the plan 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 pre-approve removal of torus palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided December 20, 2019.
You asked the Plan to pay for the dental services. You say that this procedure is to prevent additional gum decay. This type of preventive treatment will enable control of your condition and you feel it should be covered in part by the dental plan. The Plan denied your request. The Plan says this service is not covered under the plan 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. Services not listed under the description of benefits is not covered by the plan. 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 periodontal maintenance (D4910) provided December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you are extremely dissatisfied with the Plan provider and you do not trust them to perform your shoulder replacement surgery. The Plan denied your request. The Plan says out of network services are not approved unless they are not available in network or are emergent.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair and accessories.
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the enrollee has non-cancerous brain tumor which causes the enrollee to have left sided weakness. The wheelchair is having less pressure on her buttocks and less contraction on her ankle. The Plan denied your request. The Plan says Medicare specifically excludes separate coverage of durable medical equipment, which includes power wheelchairs and accessories, for members who reside in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the power wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair and accessories.
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 IRF services are necessary. The Plan denied your request. The Plan says the enrollee can safely receive the services you need in an alternative level of care.
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 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 enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that this patient requires an 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 powered upper extremity range of motion assist device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living. The Plan denied your request. The Plan says a review of the current medical literature indicates that this device is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its effectiveness. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.