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

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 based on the limited documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to currently require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 21, 2020, to September 24, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you believe the copayment amount you were charged for the September 21, 2020 date of service should be covered. The Plan denied your request. The Plan says the copayment amount 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 copayment per day for days 1 to 20, and a $100 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 4 days, resulting in a total copayment amount of $80. You have been asked to pay a $20 copayment per day for days 1 to 20, and a $100 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (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 SNF care provided from September 21, 2020, to September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 12, 2020.
You asked the Plan to pay for an LSO. You say that the requested item was legally and accurately prescribed
by the physician. The Plan denied your request. The Plan says rules for payment have not been met because
there are no medical records showing that the prescribing physician ever saw the enrollee.
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 pay for an LSO. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
that the elements of the Medicare guidelines are not satisfied by the available documentation. Therefore, the
requested item cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to
pay for an LSO (L0650) provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from
September 8, 2020, through September 24, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue. 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 subsequent nursing facility care provided from
September 8, 2020, through September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on
December 8, 2020.
You asked the Plan to waive the copayment for these services. You say that the plan documents say that the
laboratory services are included in your physical exam. The Plan denied your request. The Plan says the
copayment was 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 $10
copayment for Medicare-covered laboratory tests.
Review of the file shows that you received laboratory services on December 8, 2020. These services fall
outside of the scope of an annual physical exam. The Plan's EOC does not list laboratory services as covered in
the annual physical exam. You have been asked to pay a $10 copayment for these services. These services fall
within the Medicare-covered laboratory tests 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 laboratory services rendered on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain
indications.
Review of the file shows that the plan uses Local Coverage Determinations, (LCDs) L36129, LCD L36139,
and LCD L36523 to support their denial. However, these LCDs are not valid for the provider's billing address
state of Texas. Therefore, we are unable to use these LCDs to substantiate our decision.
The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare
covers cardiovascular disease screening tests for certain indications, the documentation does not support that
the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for
the laboratory services provided on July 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy procedure you had at an ambulatory surgical center.

You asked the Plan to waive the copayment for the endoscopy procedure. You say that this is a preventative service and it is in your best interest to make preventative services more accessible. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 for outpatient procedures and services.

You have been asked to pay a $350 for the endoscopy procedure. The endoscopy procedure falls within the outpatient procedures and services 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 procedure you had at an ambulatory surgical center.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil 200mg tablets.
You asked the Plan to pre-approve Modafinil. You say that this medication is medically necessary. The Plan denied your request. The Plan says Modafinil is not eligible for coverage under the Part B medical 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 Modafinil 200mg tablets.
Benefits for Modafinil 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the esophagogastroduodenoscopy (EGD) services provided on October 12, 2020.
You asked the Plan to waive the copay for the services provided. You say that you have never been charged a copay for this procedure. The Plan denied your request. The Plan says 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 $150 copay for outpatient surgery. The file shows that you received an EGD with a lesion/polyp removal. This is considered a surgical procedure. You have been asked to pay a $150 copay for the services provided. The services fall within the outpatient surgery 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 copay for the esophagogastroduodenoscopy (EGD) services provided on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services you received on July 23, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $10 copayment for Medicare-covered laboratory tests. Review of the file shows that you were provided lab services on July 23, 2020. You have been asked to pay a $10 copayment for the lab services. The lab services fall within the outpatient diagnostic tests 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 pay for the lab services you received on July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that your husband is not walking and if he does not have physical therapy then he cannot get stronger. You say he will be laying on the bed and falls out of the bed. You say that he needs to be able to walk, dress and do more on his own and be more independent. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet the requirements.
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 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 has a past medical history of diabetes, hypertension, and stroke. The enrollee is living at home with frequent falls and has trouble ambulating. The enrollee's 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, 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. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 29, 2020, to December 2, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that observation care could have been provided.
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 pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 29, 2020, to December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weight scale (E1639). You asked the Plan to pre-approve a weight scale. You say that the enrollee needs the requested item for daily weight monitoring for diet and lifestyle modification. The Plan denied your request. The Plan says rules for approval have not been met because there is no documentation that the enrollee is receiving dialysis. The Plan must follow Medicare rules. Medicare rules say that weight scales may be covered for patients receiving home dialysis. We looked at the file and Medicare rules. There is no indication in the provided medical records that the enrollee has kidney disease and is on dialysis. Based on this information, we decided that Medicare rules for coverage of a weight scale have not been met. Therefore, we decided that the Plan does not have to pre-approve a weight scale (E1639).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the filling for tooth # 6 provided on November 2, 2020.
You asked the Plan to pay the in network rate for the filling for tooth # 6. You say that the services were denied due to the dentist having opted out of Medicare. You also say that the provider is still listed as in network. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that the frequency limit for this service 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 frequency limit of 2 fillings per calendar year has been exceeded. The record shows that the Plan reprocessed the claim and paid the filling for tooth # 5 in addition to the filling that you received on February 18, 2020. Therefore, we decided that the Plan does not have to pay the in network rate for the filling for tooth # 6 provided on November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria
have not been met.
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 bone marrow aspiration. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research
is needed to show safety and efficacy. Iliac crest bone graft is the gold standard.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspiration.
Appeal type: SNF
Decision: Unfavorable

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system is 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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of Chronic diastolic (congestive) heart failure, as well as coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), morbid obesity, and obstructive sleep apnea. The enrollee was hospitalized on 11/26/20 with gastroenteritis. The enrollee was hospitalized on 7/28/20 with COPD exacerbation and acute-on-chronic heart failure. The enrollee was hospitalized on 6/26/20 with acute respiratory failure with hypoxia at which time she endorsed noncompliance with Lasix. 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. It is not clear that the CardioMEMS device is medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the pulp vitality test (D0460), the root canal (D3310), the incision and drainage of an abscess (D7510), and the unspecified preventive service (D1999) provided on November 6, 2020.
You asked the Plan to reimburse you for the pulp vitality test, root canal, incision and drainage of an abscess, and the unspecified preventive service. You say that you paid upfront for the dental services. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says the dental services that you received are not listed as covered services.
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 pulp vitality test (D0460), the root canal (D3310), the incision and drainage of an abscess (D7510), and the unspecified preventive service (D1999) provided on November 6, 2020.