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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested admission to an IRF.
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 enrollee does not meet criteria for the requested admission to an IRF. Our physician reviewer found the enrollee is with a past medical history of multiple sclerosis, unstable gait, anemia and arthritis with a recent right hip hemiarthroplasty who presented to the acute hospital on 06/27/2020 with a left pelvic fracture after a fall. She was treated in the hospital conservatively as no surgery for the pelvic fracture was needed. She is weak and unsteady and is working with physical and occupational therapy. She is walking 20 feet with a rolling walker with minimum assistance and is moderate assist for transfers and activities of daily living. She is medically stable. Based on the medical records provided 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 does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you require the IRF services.The Plan denied your request. The Plan says your needs can bemet 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 fileand 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. Ourphysician reviewer found 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. Your care needs can be met at an alternative 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says there wasn't documented truncal or abdomen swelling.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 2, 2019 through December 5, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were an involuntary patient. 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 $295 per day, days 1-5 for each inpatient stay. You have been asked to pay a $795 copayment, which is less than the standard copayment for the 3-day inpatient stay. The inpatient stay falls within the "Inpatient mental health 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 inpatient stay provided from December 2, 2019 through December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea second opinion to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plansays the requested services can be provided by a network provider.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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea second opinion to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 12, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that when you switched to this Plan, you assumed that you would continue to be covered by the same dental plan. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that the services were not authorized by the Plan and not emergently needed.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 12, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling & planing (D4341) provided January 31, 2020 to February 12, 2020.
You asked the Plan to pre-approve the scaling & planing. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit under your dental plan.
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 scaling & planing (D4341) provided January 31, 2020 to February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided February 18, 2020.
You asked the Plan to pay for the ambulance services. You say that your ambulance services in the past have been covered. They transported you to the hospital for your diabetes The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF services are necessary. The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternative level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 would like to appeal the Plan's denial of the requested shower chair. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on January 23, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you requested a list of network providers from the Plan. You also say that the Plan said that they sent you the wrong list of providers. 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 panoramic x-ray provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and maxillary partial denture provided on August 15, 2019 and October 10, 2019 by an OON provider.
You asked the Plan to pay for the panoramic x-ray and maxillary partial denture. You say that you went out-of-network because there were not any prosthodontists in the area. The Plan denied your request. The Plan says you received dental care at an OON provider. The Plan also says that these are Plan covered services, but they are only covered when they are received from a dentist that participates within the Plan's dental provider network.
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 covered when they are received OON. The Plan says that there are network prosthodontists available within the Plan's network of providers. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and maxillary partial denture provided on August 15, 2019 and October 10, 2019 by an OON provider.
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 require the IRF services. The Plan denied your request. The Plan says you can safely receive the services you need in other settings.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is ambulating hundreds of feet. The enrollee's care needs can be met at an alternative level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea stair lift.You asked the Plan to pre-approvea stair lift. You say that the requested stair lift is medically necessary for you and is not for convenience. You say that you have two herniated discs in your lower spine and no cartilage in your right knee. You stated that you have fallen twice and after the last fall you were unable to walk for several weeks. You asked the Plan to list the item as medically necessary and provide coverage for it.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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-approvea stair lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health care provided April 5, 2020 to April 10, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $425 copayment per day, for days 1-3 and a $0 copayment per day, for days 4-90 for each in-network inpatient mental health care admission. You have been asked to pay a $1,275 copayment ($425 x 3 days) for the inpatient mental health care. 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 inpatient mental health care provided April 5, 2020 to April 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol Hcl (J8499).
You asked the Plan to pre-approve Tramadol Hcl. You say that the requested medication is necessary. The Plan denied your request. The Plan says that you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Tramadol Hcl (J8499).
Benefits for Tramadol Hcl 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: 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 would like to appeal the Plan's denial because you need the requested equipment. You say that you recently suffered a fall in your home and your treating physician does not recommend that you stand while bathing. You stated that you are weak and you have remained in bed since the incident occurred. You say that you live alone which makes it difficult for you to bathe. You asked the Plan to reconsider their denial. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous transcatheterleft atrial appendage closure (LAAC) (33340). You asked the Plan to pre-approvepercutaneous transcatheter LAAC. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is not enrolled in a CMS approved registry.The Plan must follow Medicare rules. Medicare rules say that LAAC is only covered if  patient is enrolled in, and the MDT and hospital must participate in, a prospective, national, audited registry that: 1) consecutively enrolls LAAC patients,and, 2) tracks the above annual outcomes for each patient for a period of at least 4 years from the time of the LAAC.We looked at the file and Medicare rules. The record does not show that the enrollee is enrolled in a CMS approved registry.Based on this information, we decided that Medicare rules for coverage of percutaneous transcatheter LAAC have not been met.Therefore, we decided that the Plan does not have to pre-approvepercutaneous transcatheter left atrial appendage closure (LAAC) (33340)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve and additional crown tooth 30 (D2740) core buildup, including any pins when required (D2950x2) and pulp cap - indirect, excluding final restoration, (D3120x2).
You asked the Plan to pre-approve the dental services. You say that the enrollee's existing PFM crown has nickel properties and she has an allergy to nickel and has constant allergic localized reaction. Please consider for payment as this is medically necessary. The Plan denied your request. The Plan says the benefit maximum has been for a crown as the health plan contract allows coverage for 1 crown per year. Core build ups and pulp caps are 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. The health plan contract allows coverage for 1 crown per year. The records show that a crown was previously approved. There is no coverage for core buildup or pulp caps. 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 and additional crown tooth 30 (D2740) core buildup, including any pins when required (D2950x2) and pulp cap - indirect, excluding final restoration, (D3120x2).
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 are unable to get in and out of your tub safely due to your bad knees and weight. You asked the Plan to reconsider providing coverage for the requested shower chair. 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.