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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a need for an intensive team, and no need to be seen by a rehab doctor 3 times a week.
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 was medically stable, with no evidence of need for supervision by a PMR Physician. There is no need for acute rehab nursing care. Functionally given minimum assist and CGA level, the enrollee does not need IRF admission. The enrollee may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 for the enrollee. You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not need to be seen by a rehab doctor at least three times a week or an intensive team for her 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. The patient was medically stable with no evidence of need for supervision by physical medicine and rehab physician or the need for acute rehab nursing care. Functionally given she is at minimum to contact guard assist level she does not need IRF admission. The patient may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF services. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean oral consultation with a periodontist.You asked the Planto pre-approvethe consultation. You say that this is medically necessary.The Plandenied your request. The Plansaysthe plan only covers dental services provided by a participating general dentist.Medicare generally does not cover dental services. However, thePlan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental services when provided by a participating general dentist.The requested services are not to be provided bya general dentist. A periodontist is not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the consultation have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean oral consultation with a periodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 29, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 a domiciliary, rest home visit provided on November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute care hospital with multiple abscesses and sepsis. The enrollee was diagnosed with pneumonia. A tracheostomy and a PEG tube have been placed. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition can be taken care of in sub-acute rehab or a SNF.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not indicate that the enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies; however, the enrollee's functional level does not indicate that this therapy can be tolerated in an IRF with an intensive level program. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram provided on January 23, 2020.
You asked the Plan to waive the deductible for the mammogram. You say that you have been doing thermograms instead of mammograms for years. You say that the claim should be reimbursed. The Plan denied your request. The Plan says the deductible applied correctly.
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 your out-of-network (POS) deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered out-of-network (POS) medical services. Until you have paid the out-of-network deductible amount, you must pay the full cost of your covered out-of-network services. The item or service you asked the Plan to waive the deductible for falls within the "Breast cancer screening (mammograms)" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 out-of-network (POS) deductible applies to out-of-network mammograms. This cost sharing is a contractual obligation that had not been met at the time the mammogram was received on January 23, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the mammogram provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lactulose hydrogen breath test for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says lactulose breath hydrogen for diagnosing SIBO is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. The requested test is statutorily excluded from coverage. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve a lactulose hydrogen breath test for the enrollee.
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 want to appeal the Plan's denial of the shower chair because of its necessity. 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 power seat elevation feature. You asked the Plan to pre-approve a power seat elevation feature. You say that you need a Group 3 power wheelchair, accessories, and a power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) provided on December 18, 2019.
You asked the Plan to pay for the bitewings. You say that you were not advised that bitewings would not be covered. You also say that you were advised that the provider was in-network, and the services would be covered. The Plan denied your request. The Plan says this service is not a covered benefit.
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 bitewings (D0274) provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit provided on February 11, 2020.
You asked the Plan to reduce the copayment for the office visit. You say that the vision copayment should be $10 even if you have a drug injection. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record show that the office visit was billed by a specialist. 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 reduce the copayment for the office visit provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you feel you need more extensive care at the IRF.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy oroccupational therapy, and an intensive rehabilitation therapy program. Your rehabilitation needs can be met in a lower intensity setting such as a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Basedon 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says further care can be received in the home with home PT and home health.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the enrollee.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 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 was admitted to the hospital for the treatment of COPD exacerbation. The enrollee required minimal assistance with walking 50 seconds with a rolling walker. The enrollee required moderate independence with a rolling walker to stand. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not indicate that this therapy can be tolerated in an IRF with an intensive level program. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that that enrollee will benefit from acute rehab to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says that the enrollee's condition can be managed in sub-acute rehabilitation or a skilled nursing facility.
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. The patient's current medical status does not require intensive physician or nursing oversight in an IRF. The patient may benefit from additional multiple therapies; however, the patient's functional level does not indicate she can tolerate this therapy in an IRF with an intensive level program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF services. 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for cataract surgery provided on December 13, 2018 and January 15, 2019.You asked the Plan to reimburse you for the cataract surgery. You say that the in-network provider had expressed doubt for a successful outcome. The Plan denied your request. The Plan says 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 reimburse you 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 reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for cataract surgery provided on December 13, 2018 and January 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cialis.You asked the Plan to pre-approve the Cialis. You say that the enrollee needs this medication and other options have been tried.The Plan denied your request. The Plan says the enrollee does not have part D coverage through this plan.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 Cialis.Benefits for the Cialis may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.