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

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the enrollee still requires nursing care, and is more medically advanced than what a SNF could perform. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for leukemia and myelodysplastic syndrome. The enrollee has experienced a series of complications related to his treatment (mucositis, infections, DVT, bleeding), resulting in a prolonged hospitalization. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an acute inpatient hospital admission for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The
Plan denied your request. The Plan says that the services are not medically necessary.
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 pre-approve acute inpatient hospital care. Our
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee presented to
the hospital with nausea, vomiting, and abdominal pain with a cough for the past five days. A chest x-ray
showed increasing size and quantity of nodular densities in the right and mid upper thorax. The findings were
suggestive of an infectious or inflammatory etiology. The records support that the admitting physician could
reasonably expect that the enrollee would require at least two midnights of inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pre-approve an acute inpatient hospital admission for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from February 1, 2019 through May 7, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
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 inpatient hospital care. Our physician reviewer found the documentation states the enrollee's family declined the recommended transfer. The enrollee remained on the inpatient service until May 7, 2019 when his family permitted transfer to a skilled nursing facility. Ongoing inpatient care is not determined reasonable and medically necessary starting on January 29, 2019.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 hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from February 1, 2019 through May 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine for enrollee.You asked the Plan to pre-approve Morphine. You say that the enrollee has been on Morphine in the past with good results.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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 Morphine for enrollee.Benefits for Morphine 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 incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need the incontinence supplies to prevent accidents. You say that your Doctor has stated that the diapers are medically necessary for you and help prevent infections. 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 incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 15, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you should get the MRI for free. 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 $275
copayment for each advanced imaging service.
You have been asked to pay $232.11, which is less than the standard $275 copayment for the MRI. The MRI
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the MRI provided on October 15, 2019.
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 enrollee will require the daily medical management of nephrological, wound, and neuro changes, as well as the expertise of IP acute therapy. The Plan denied your request. The Plan says a SNF level of care has been recommended alternatively.

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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid tablets.
You asked the Plan to pre-approve Synthroid. You say that you cannot take the generic type of drug. The Plan denied your request. The Plan says Synthroid to be taken at home is not covered under your Part B 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 Synthroid tablets.
Benefits for Synthroid 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mandibular partial denture (code D5214).You asked the Plan to pre-approvethe denture. The Plan denied your request. The Plan says this service exceeds the benefit allowance.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, complete or partial dentures are limited to 1 set every five years. The record shows that you received a mandibular partial denture on June 22, 2019 and your partial denture benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea mandibular partial denture (code D5214).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee on June 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that a decision was not made within the time frame.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. A bronchoscopy is Medicare-covered service. The plan has not provided documentation showing that the coverage criteria for the bronchoscopy have not been met. Without supporting documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided to the enrollee on June 4, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have urinary incontinence while in the bed and while walking. 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 incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 4, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspensionsleeve (L1851, L2397) provided to the enrollee on September 4, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of the torus mandibularis (D7473) provided on February 28, 2019.You asked the Plan to pay forthe dental service. You say that the removal of the torus mandibularis is medically necessary. You say that this needed to be done in order for you to be fitted with a lower partial denture.The Plan denied your request. The Plan says the removal of torus mandibularis is not a covered service.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 Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the service you received was not medically necessary. Our physician reviewer found the low quality x-rays that were provided do not show the need of having the tori removed. The reviewer found there were no notes provided to support the sizeof the tori. The reviewer also says there are no clear signs of the tori seen on the provided x-ray. Therefore the service was not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met.Therefore, we decided that the Plan does not have to pay forthe removal of the torus mandibularis (D7473) provided on February 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you are suffering from pain. The Plan denied your request. The Plan says the services are available in-network.
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 pre-approved care. 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 medical services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded J9047 provided on August 23, 2019.You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the 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 J9047 is Injection, carfilzomib, 1 mg.We find that CPT code J9047 is not supported in the medical record. Specifically, the documentation submitted did not support that 120 units of carfilzomib was administered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met.Therefore, we decided that the Plan does not have to pay for the injection services coded J9047 provided on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lower partial denture (D5212).You asked the Plan to pre-approvethe dental item. You say that you had a roof leak and water damage in your bathroom.  You say that your lower partial denture had mold in it. You say that you had no choice but to throw it out.The Plan denied your request. The Plan says the frequency limit for partial dentures has been reached. The Plan also says that you received a lowerpartial denture on April 5, 2018.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 and partial dentures are a covered item, the frequency limit has been reached. The Plan last paid for a lower partial denture that you received on April 5, 2018.Therefore, we decided that the Plan does not have to pre-approvea lower partial denture (D5212).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ambulance ride provided on August 15, 2019.
You asked the Plan to reduce the copayment for the ambulance ride. You say that you have never paid more than a $100 copayment for ambulance services. 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 $325 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $325 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 reduce the copayment for the ambulance ride provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Mohs surgery services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON surgery services. You say that the enrollee needs to be treated by a provider who is fellowship trained in Mohs surgery. Someone without this Mohs training would not have the expertise to provide this care properly. The Plan denied your request. The Plan says the plan's network has specialists with board certification in Mohs surgery. This doctor has this expertise and can treat the enrollee.
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 pre-approved care. 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-approve the Mohs surgery services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged hospitalization and the intensive skilled services offered in the LTACH setting. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for pancreatic cancer. His post-operative course was complicated by a gastric perforation requiring additional surgery. The enrollee was intubated/ventilated and eventually received a tracheotomy. He has since been weaned from the ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.