Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy you had on June 9, 2020.You asked the Plan to waive the copayment forthe endoscopy. You say that you don't believe that an endoscopy should be considered a surgical service.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 $200 copayment for outpatient surgery services. You have been asked to pay a $200 copayment for the endoscopy. Medicare guidelines state that endoscopies are considered minor surgical procedures. That is why the endoscopy falls within the outpatient surgery 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 forthe endoscopy you had on June 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forphysician services provided by an out-of-network provider on August 13, 2019, to June 16, 2020.You asked the Plan to pay forphysician services. You say that these services were provided in good faith.The Plan denied your request. The Plan says that prior authorization was not obtained.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 regardingtheir decision to deny your request. A 2019 EOC was not provided to us; therefore, the appeal has been overturned.Therefore, we decided that the Plan has to pay forphysician services provided by an out-of-network provider on August 13, 2019, to June16, 2020.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 pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF would be the best option for this patient. The
Plan denied your request. The Plan says the enrollee would benefit from therapy but does not need frequent
physician oversight in the acute hospital setting.
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 is a 72-year-old female with a past medical history of hypertension and
metastatic breast cancer who presented to the acute hospital on 12/03/2020 with lower extremity weakness and
loss of bladder control related to spinal cord compression from metastatic disease versus arthritis. She was
treated in the hospital with neurosurgical consultation and spinal decompression surgery. She is weak and
deconditioned and is working with physical and occupational therapy. She is walking 60 feet with a wheeled
walker with minimal assistance and is contact guard assist for transfers and stand by assist to contact guard
assist for activities of daily living. She is noted to have fatigue and pain with therapy. Based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs
do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
patient does require physical therapy and occupational therapy services, but the patient does not require an
intensive inpatient rehabilitation therapy 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: Surgery
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approvecomputer-assisted  navigation  for  a knee implant replacement.You asked the Planto pre-approvethe procedure.  You  say that this  is  medically  necessary.The  Plandenied your  request. The Plansaysthis  is considered  investigational  as a treatment  option.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  the procedure.  Our reviewer  says  that the  requested  procedure  is  not considered  medically  reasonable  and necessary  in  this  case. Our physician reviewer  found  the  enrollee  is  indicated  for left  total  knee arthroplasty.  Under  consideration  is  a request  for computer-assisted  navigation  for  the approved  left  total  knee replacement.  Current  evidence  based medical literature  does not  support  the routine  use of computer-assisted  navigated  total  knee  arthroplasty  over conventional  total knee arthroplasty.  The enrollee  reports that his leg is not straight,  but the physician's  clinical exam  did not  evidence  significant  malalignment.  There  is  no specific  indication  provided  by the physician  to support  the  medical  necessity  of computer-assisted  navigation  for this enrollee's  approved left total knee replacement.  Therefore,  this  request  for computer-assisted  navigation  for  the  approved left  total  knee arthroplasty  is  not  medically  reasonable  and 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 the  procedure  have  not  been met.Therefore,  we decided that the  Plandoes not haveto pre-approvecomputer-assisted  navigation  for  a knee implant  replacement.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean MRI of the abdomen and pelvis.You asked the Plan to pre-approvean MRI of the abdomen and pelvis. You say that the requested MRI of the abdomen and pelvis are medically necessary.The Plan denied your request. The Plan says the requested MRI of the abdomen and pelvis are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI of the abdomen and pelvis. Our reviewer says that the requested MRI of the abdomen and pelvis are not medically necessary. Our physician reviewer found the enrollee is with vulvar cancer. Per NCCN guidelines, surveillance involves CT or PET/CT if recurrence/metastasis is suspected. The requestedMRI of the abdomen and MRI of the pelvis are not medically necessary at this time.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 MRI of the abdomen and pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approvean MRI of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator (E1392).You asked the Plan to pre-approvea portable oxygen concentrator. You say that you cannot carry oxygen tanks.The Plan denied your request. The Plan says your needs could be met with portable oxygen tanks.The Plan follows Medicare rules. Medicarerules say that portable oxygen concentrators are covered when they are medically necessary according to the above guidelines. 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 portable oxygen concentrator. Our reviewer says that the requested portable oxygen concentrator is not medically necessary in this case. Our physician reviewer found the submitted records show that you have resting hypoxemia, but there is no documentation that oxygen corrects this or what flow rate is necessary to accomplish this. In addition, there is no justification of the need for a portable oxygen concentrator or why portable tanks would not meet your needs.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 portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthosis provided on July 9, 2020.You asked the Plan to pay forthe services provided. You say that the enrollee cannot ambulate without pain and discomfort.The Plan denied your request. The Plan says without a face-to-face encounter, the physician could not gather the necessary information.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a validphysician order, or proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe orthosis provided on July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe second ambulance transport you had on August 10, 2020.You asked the Plan to waive the copayment forthe second ambulance transport. You say that you shouldn't have to pay a copayment for this second ambulance transport. You say that you were transported to the first hospital vial ambulance.  You then had to be transported to a second hospital via ambulance because you required a test that was unavailable at the first hospital. You say that it is unfair to have to pay copayments for both transports.The Plan denied your request. The Plan says you were charged both ambulance copayments correctly.The rules say a plan must disclose to itsenrollees 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 $250 copayment for each separate one-way ambulance service. You have been asked to pay a $250 copayment for the second ambulance transport. Your Evidence of Coverage clearly states that you pay this copayment for each separate transport.  This copayment applies regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe second ambulance transport you had on August 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forthe  root canal  (D3310) provided  on July  28, 2020.You asked the  Plan to pay  forthe  dental  service.  You  say that you  were lead  to believe  that  your  root canal would  be covered.  You also  say that  you  cannot  afford  this  bill.The  Plan  denied  your  request.  The  Plan  says root canal  is not  listed  as 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.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 forthe root canal  (D3310) provided  on July  28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee genicular nerve block with fluoroscopy.You asked the Plan to pre-approvea knee genicular nerve block with fluoroscopy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that knee genicular nerve block with fluoroscopy is only covered for certain indications.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 knee genicular nerve block with fluoroscopy. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewerfound the enrollee has chronic knee pain from osteoarthritis. The enrollee has tried PT, Massage, heat/ice, stretching, non-opioid analgesics and intra-articular steroids and viscosupplementation. The request is considered an experimental/ investigationaltechnique that is the subject of on-going clinical trials. The enrollee is not enrolled in a clinical trial. Therefore, the enrollee does not meet criteria for the requested 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 a knee genicular nerve block with fluoroscopy have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee genicular nerve block with fluoroscopy
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services on December 28, 2018.
You asked the Plan to pay for the emergency department services. You say that the claim was refiled late because you did not receive the EOB timely. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency department services was not filed until July 2, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency department services on December 28, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish and
prophylaxis provided on March 18, 2019.
You asked the Plan to pay for the topical application of fluoride excluding varnish and prophylaxis. You say
that your plan covers 2 dental cleanings per year, but you receive 3 cleanings per year. You also say that you
were told being billed for these services was a mistake. The Plan denied your request. The Plan says your
benefits for these services have been exhausted.
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, cleanings are limited to one every 6
months, and fluoride treatment is limited to 1 every year. The record shows that you received a topical
application of fluoride and prophylaxis on July 2, 2019, and your cleaning and fluoride treatment benefits have
been exhausted. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride
excluding varnish and prophylaxis provided on March 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain fused to predominantly basemetal crown and core buildup services.You asked the Plan to pre-approvea porcelain fused to predominantly base metal crown and core buildup services. You say that you would like the plan to reconsider their denial.The Plan denied your request.The Plan says the requested services are 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.Review of the file shows that while the plan does cover certain crowns, the plan does not cover the requested crown identified with code D2751. The requested core buildup services are not covered. 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-approvea porcelain fused to predominantly base metal crown and core buildup services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental implants.You asked the Plan to pre-approvedental implants. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 thiscase.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-approvedental implants.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forroutine ambulance supplies (A0398).You asked the Plan to pay forroutine ambulance supplies. You say that this should be covered.The Plan denied your request. The Plan says this is not separately payable from the transportation charge.The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services.We looked at the file and Medicare rules. The items at issue are not separately payable from the ambulance services. Based on this information, we decided that Medicare rules for coverage of routine ambulance supplies have not been met.Therefore, we decided that the Plan does not have to pay forroutine ambulance supplies (A0398).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are at high risk of falling and he cannot complete his daily activities.The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee does not have anywhere else to go. The appellant says that the records provided support the need for care in an LTACH.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee 's care can be provided in the current inpatient hospital.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 current acute care hospital with diabetic ketoacidosis, acute kidney injury, uncontrolled hypertension, and COVID-19 pneumonitis requiring intubation/mechanical ventilation and later tracheostomy as well as PEG tube, antibiotics, Remdesivir, Decadron, and blood transfusions for a GI bleed. He was weaning off the ventilation recently but is still encephalopathic due to recent UTI and recent GI bleed which requires additional treatment and monitoring. The enrollee appears to have improved but is currently unstable to where they require additional short-term acute care services that can safely be completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not available at the current facility or lower level of care. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when the enrollee's treatment has completed and they are more stable.
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-approvelong-term acute care hospital (LTACH) services