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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health care, or in a long-term care 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have no complex wound care or other skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. Therefore, you do 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.

You asked the Plan to pre-approve genicular radiofrequency ablation. You say that you would like
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says this
service is considered experimental.

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 genicular radiofrequency ablation. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of ongoing
clinical trials.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided
that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.

You asked the Plan to pre-approve CardioMEMS. You say that you would like reconsideration because the
CardioMEMS HF System implant is medically reasonable and necessary. The Plan denied your request. The
Plan says CardioMEMS can only be covered within the context of a Medicare approved study.

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 CardioMEMS. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further
clinical study is needed to determine the efficacy and safety of this device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not
have to pre-approve CardioMEMS.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex spacer.

You asked the Plan to pre-approve the Vertiflex spacer. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says there is not enough evidence to support this service.

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 Vertiflex spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy.

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 Vertiflex spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex spacer.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found you have documented skilled therapy needs. You are functioning below baseline. The documentation does not support that you have reached a plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Therefore, you 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional physical therapy visits.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the plan approved one of the six requested visits and denied the remaining five. The additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy of 28 outpatient visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been instructed in and is performing a home exercise program. The requested services are not part of a maintenance 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 the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve True Metrix Test Glucose Test Strips.

You asked the Plan to pre-approve the test strips. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee must use the Plan-approved brands of Accu-Chek or OneTouch.

The Plan must follow Medicare rules. Medicare rules say that, unless there is a special circumstance, the enrollee must use Plan-approved brands. The brand requested is not a plan approved brand. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve True Metrix Test Glucose Test Strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.

You asked the Plan to pre-approve SNF admission. You say that you would like reconsideration because the
SNF admission is medically necessary. The Plan denied your request. The Plan says it is not reasonable or
necessary to receive inpatient SNF level therapy for a member who is functioning at their physical baseline.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the intermittent skilled services can be
provided at a lower level of care than a skilled nursing facility. The member does not have any parental
medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute
exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive
services at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission for a right total knee arthroplasty for the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case, the documentation does not indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights based upon the enrollee's medical condition. The elements of the coverage rule are not satisfied.

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 not been met. Therefore, we decided that the Plan does not have to pay for inpatient admission for a right total knee arthroplasty for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015).

You asked the Plan to pay for an eye refraction. You say that you requested an eye examination with refraction
because you believed you may need a change in your eyeglass prescription. The Plan denied your request. The
Plan says the service is a covered benefit, but you have exceeded the frequency limit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of an eye refraction have not been met. Specifically, the record indicates that you had exceeded the
frequency limit prior to this service. Therefore, we decided that the Plan does not have to
pay for an eye refraction (92015).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper right and lower right quadrants, and a porcelain crown for tooth # 29.

You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says scaling and root planing is limited to once per quadrant every 2 plan years. The Plan says that crowns are covered once per tooth every 5 plan years. The Plan also says that the frequency limits for these services have been reached.

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 the services are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for scaling and root planing for the upper right and lower right quadrants. The record also shows that the Plan paid for a crown that you received for tooth # 29. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4342) for the upper right and lower right quadrants, and a porcelain crown for tooth # 29.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, and panoramic x-ray. We decided that the Plan does not have to pay for the endosteal implant.

You asked the Plan to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, panoramic x-ray, and endosteal implant. You say that you were charged for a service you did not receive. The Plan says that implant dental services are not recognized as a covered benefit under your Plan. The Plan also says that the x rays were taken for the treatment of sinus augmentation and implant placement.

We decided that the Plan has to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, and panoramic x-ray.

Medicare rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.

The Plan contract says that 1 panoramic x-ray is covered every three years. The contract also says that 4 intraoral periapical x-rays are covered per year. You reasonably believed the intraoral x-rays and panoramic x-rays would be covered because the EOC states no other limitations regarding these services, the records do not show that these benefits had been exhausted, nor does the EOC specifically state that services provided in conjunction with implants will not be covered. Therefore, we decided that the Plan has to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, and panoramic x-ray.

We also decided that the Plan does not have to pay for the endosteal implant.

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. The contract clearly states that implant abutment supported dentures and their components are not allowed. Therefore, we decided that the Plan does not have to pay for the endosteal implant.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services and the ER visit.

You asked the Plan to waive the copayment for the laboratory services and ER visit. 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 $10 per day, per provider, for Medicare-covered lab services and $90 for each Medicare-covered emergency room visit.

You have been asked to pay a $10 copayment for the laboratory services and a $90 copayment for the ER visit. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ER visit falls within the "Emergency 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 laboratory services and the ER visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471) and a removal of torus palatinus (D7472).

You asked the Plan to pre-approve the removal of lateral exostosis and removal of torus palatinus. You say that you feel this is the only viable treatment option for the edentulous area to accommodate the full upper denture. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.

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 a removal of lateral exostosis (D7471) and a removal of torus palatinus (D7472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the photochemotherapy.

You asked the Plan to reduce the copayments for the photochemotherapy. You say that you are overpaying an amount of $23.57 per visit. You say the allowed amount has not changed for the services. The Plan denied your request. The Plan says the claims were previously processed incorrectly toward radiation therapy. The claims are now processing correctly, and you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for provider and professional services at an in-network specialist's office physician's office.

The enrollee has been asked to pay a $45 copayment for the photochemotherapy for each visit. The photochemotherapy falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for the photochemotherapy.