Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre device.
You asked the Plan to pre-approve a Freestyle Libre device. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre device. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee is noted to have diabetes, for which she takes oral medications and a set dose of once daily insulin. There is no evidence that the enrollee uses the results of blood glucose testing to adjust her insulin dose multiple times per day. As such, a CGM is not shown to be medically necessary or reasonable. 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 Freestyle Libre device have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Freestyle Libre device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital bed (E0303).
You asked the Plan to pre-approve a hospital bed. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 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 hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee has a weight of 230 pounds per a May 27, 2021 progress note. A heavy duty extra wide hospital bed (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 18, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were not happy with the service you received in 2020 so you found another provider. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had
exceeded the frequency limit prior to this service on {date}. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on January 19, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you are not a new patient and you have been seeing this dentist for years. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had
exceeded the frequency limit prior to this service on June 9, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on January 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy services (90837) provided March 27, 2020.
You asked the Plan to waive the copayment for psychotherapy services. You say that you were not aware the provider was out of network The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $40 copayment for outpatient mental health care. You have been asked to pay a $40 copayment for psychotherapy services. This service falls within the outpatient mental health care benefit category. Although the provider is considered out of network, the Plan has waived this network requirement due to your emergency. Therefore, the Plan has agreed to charge the in-network copayment rate of $40. 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 psychotherapy services (90837) provided March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor provided January 8, 2021, to March 8, 2021.

You asked the Plan to waive the coinsurance for the continuous glucose monitor. You say that you believe diabetic supplies are to be paid one hundred percent.The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.

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 20% coinsurance for durable medical equipment. 

You have been asked to pay a total cost share of $155.2 for the continuous glucose monitor services ($777.60 Medicare allowed amount x 20% coinsurance). These services fall within the durable medical equipment 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 coinsurance for the continuous glucose monitor provided January 8, 2021, to March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 16, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you paid a copayment already. You say that you have never had to pay anything for the injection before. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20% coinsurance for Medicare Part B prescription drugs/network. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $150. The total amount you are being asked to pay is $30 ($150 x 20% = $30). The correct
coinsurance has been applied. An injection falls within the Medicare Part B prescription drugs/network 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 coinsurance for an injection provided by a participating provider on November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee arthroscopy.
You asked the Plan to pre-approve a knee arthroscopy. You say that this requested surgery is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that arthroscopy surgery is subject to the criteria listed 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 the knee arthroscopy. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found that the medical records show that the patient has advanced degenerative joint disease of the knee. Arthroscopy is not indicated in cases of advanced degenerative joint disease of the knee without other significant pathology.
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 knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee arthroscopy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the outpatient medications provided from January 28, 2020, to March 9, 2020.
You asked the Plan to reimburse you for the outpatient medications. You say that you paid for these services out of pocket while you were overseas. You also say that you should be reimbursed. The Plan denied your request. The Plan says drugs purchased outside of the United States are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 outpatient medications have not been met. Therefore, we decided that the Plan does not have to reimburse you for the outpatient medications provided from January 28, 2020, to March 9, 2020.
Benefits for the outpatient medications 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 6, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on October 6, 2020 by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve the inpatient hospital admission. You say that the medical records provided support that an inpatient hospital stay is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan says that the planned procedure is not listed on the CMS Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure and there is no documentation provided to support the expectation the enrollee will require a greater than a two midnight stay. The Plan says that if the member experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the notes show that the enrollee is stable and has no medical history significant to suggest they would be at high risk for this procedure to warrant inpatient hospital services. Based on the documentation provided, the enrollee would not be expected to warrant hospital services that would likely cross 2 midnights related to this procedure. 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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the case presentation, detailed and extensive treatment planning (D9450) or pay an additional amount for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x8) received March 10, 2021.
You asked the Plan to pay for the case presentation, detailed and extensive treatment planning (D9450) or pay an additional amount for the teeth extractions. You say that the Plan should pay more of the cost for the requested services. The Plan denied your request. The Plan says there is no coverage for case presentation treatment planning. The correct cost share applied to the eight tooth extractions.
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 case presentation, detailed and
extensive treatment planning (D9450) is not among those covered under this benefit. The Plan offers coverage for tooth extractions (D7140). An individual tooth extraction requires an $84 copayment. You have been asked to pay $448 in copayments for the eight extractions. This amount is less than the required copayment of $84 per extraction. This cost sharing is a contractual obligation you agreed to when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the case presentation, detailed and extensive treatment planning (D9450) or pay an additional amount for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x8) received March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a gastroenterologist on March 25, 2021.
You asked the Plan to waive the copayment for the gastroenterology visit. You say that you should have never paid this bill. 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 $25 copayment for specialist visits. You have been asked to pay a $25 copayment for the gastroenterology visit. The gastroenterology visit falls within the specialist visits 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 office visit you had with a gastroenterologist on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 in this case, the enrollee was admitted with respiratory failure due to sepsis from pneumonia and with acute kidney injury. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving that would be available at the LTACH facility. The elements of the coverage rules are not satisfied as the current acute care services are sufficient. 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: 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 care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 daily skilled services are not necessary. Our physician reviewer found that in this case, the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, 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. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF care 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the enrollee's recovery. The Plan denied your request. The Plan says the enrollee's needs can be met in 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 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 with hypercapnic respiratory failure due to pneumonia. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 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.