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

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 24, 2021, to 
February 25, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's signs and symptoms of 
cocaine induced chest pain was severe enough to warrant the need for medical care and services deemed safe 
and effective on an inpatient basis. The Plan denied your request. The Plan says that criteria was not met for 
inpatient admission. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that based on the provided documentation, the presenting positive troponin and T-wave changes 
on electrocardiogram warranted telemetry and a completed workup to rule out acute coronary syndrome which 
was expected to cross 2 midnights.  
 
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 pay for the acute inpatient hospital care provided from February 24, 2021, to February 25, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740) on tooth #8.
You asked the Plan to pre-approve the crown. You say that the requested crown is necessary. The Plan denied your request. The Plan says a cap cannot be approved for a tooth that has an inadequate fill from a root canal treatment.
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 crown 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 pre-approve the crown. Our reviewer says that upon review of the radiograph of tooth #8, it is noted that a post has been inserted into the root canal space. The root canal fill does not reach the apex, which is the standard of care. Also, there appears to be a radiolucency at the apex which may be pathological. It is my opinion that the inadequate root canal fill be evaluated prior to the approval of a crown restoration. The present documentation does not meet the criteria for coverage.
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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740) on tooth #8.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve sixteen (16) physical therapy visits (97163, 97110) provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical therapy visits. You say that you have searched for providers in your area, and they are more than an hour away and have backed up appointments for months. You also say that you are injured, in pain and need therapy soon. The Plan denied your request. The Plan says that there are in-network providers available for these services.
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. Specifically, the Plan has not provided proof that there are accessible, equally qualified providers that can provide the services at issue. Without this information, the denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pre-approve sixteen (16) physical therapy visits (97163, 97110) provided by an out-of-network (OON) provider.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bystolic 5MG tablet, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication since 2015 with well control of blood pressure and chest pain. You state the enrollee has tried other medications. The Plan denied your request. The Plan says Bystolic 5MG tablet to be administered at home is not Medicare covered under the Part A or 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 Bystolic 5MG tablet, for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says the requirements for approval have not been met. The Plan says that the enrollee has reached reasonable expectations for improvement and is medically stable. The Plan says that the enrollee has no acute symptoms that require 24-hour inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our
reviewer says that the criteria for coverage of inpatient psychiatric care have not been met. Our physician
reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on July
17, 2021, with Bipolar Disorder, Current Episode Mixed, Severe with Psychotic Features. Based upon review
the records provided it was not expected this enrollee would improve in a reasonable period of time for the
dates in question as she did not have suicidal or homicidal ideation noted and no auditory or visual
hallucinations. This enrollee did not show any abnormal behaviors or any symptoms which would require acute
treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute
inpatient level of care rather than a lower level of care beyond the dates in question as she did not have
dangerousness to self or others but was compliant with her treatment.
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 psychiatric services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient psychiatric services.
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 an LTACH is medically necessary to 
manage the enrollee's ongoing complex medical needs. A lower level of care would not be adequate. The Plan 
denied your request. The Plan says criteria for an LTACH are not met, and the enrollee is receiving proper care 
at the current hospital. An LTACH would not offer a therapeutic advantage. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that is not available at the acute care hospital where they are currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis. 
 
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: 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 not 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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that is not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: 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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with with a left basal ganglia hemorrhage with midline deviations and required an external ventricular drain. He patient appears to be more stable and only requires a short-term additional acute care services to complete treatment, which can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current
facility. The LTACH services are therefore not reasonable or 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1852) for the enrollee.
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says there is no recent injury or surgery to the knee.
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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided for review does not support any recent injury or surgery to the knee. There is no documentation of objective findings for the bilateral knees to demonstrate instability. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for knee orthosis (L1852) is not medically reasonable or 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1852) for the enrollee.
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 that you were admitted for hypertensive emergency and bronchitis. Medical 
conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. Although you do require physical and occupational therapy, there is no documented need for 
an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 
In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the chest. You say that this request is medically necessary. The Plan denied your request. The Plan says metastatic disease should first be diagnosed by tissue biopsy.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the chest. Our reviewer says that this requested imaging service is not medically necessary. Our physician reviewer found the review indicates that the enrollee is an 84 year old female with a past medical history of right forearm melanoma excised in 2014 and determined not to have metastasized who presented to her primary care physician with a non-tender right axillary mass of unknown duration. In this case, imaging is supported for a biopsy-proven recurrence of melanoma. The clinical information submitted by your provider does not confirm a biopsy proven recurrence. Therefore, the requested CT Scan is not medically reasonable or 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 a CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says criteria for an IRF are not met, and the necessary services can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation 
(A0427, A0425) provided on February 22, 2021. 
 
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you did not 
receive these services. The Plan denied your request. The Plan says the copayment was 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 $240 
copayment for ambulance services.  
 
You have been asked to pay a $240 copayment for emergency ambulance transportation. The services at issue 
fall 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 waive the copayment for 
emergency ambulance transportation (A0427, A0425) provided on February 22, 2021.  
 
Your complaint about not receiving these services is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.