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

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for cellulitis and peripheral artery disease of the lower leg and had a below the knee amputation. His medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HBOT.
You asked the Plan to pre-approve the HBOT. You say that you would like reconsideration because HBOT is being requested to minimize the chance of Osteoradionecrosis (ORN). The Plan denied your request. The Plan says use of HBOT for prevention of possible ORN is not a covered indication
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 HBOT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prevention of possible ORN is not covered indication for HBOT. 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 HBOT have not been met. Therefore, we decided that the Plan does not have to pre-approve HBOT.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing/panels (CPT code(s): 81291, 81405, 81406, 81406, 81407, 81408, 81479 and 81439) provided to the enrollee on July 30, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Medicare denies coverage for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. Therefore, we decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing/panels (CPT code(s): 81291, 81405, 81406, 81406, 81407, 81408, 81479 and 81439) provided to the enrollee on July 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network inpatient rehabilitation
facility (IRF).
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this requested service is available from participating providers in the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the full amount you paid for the ankle foot orthosis purchased on April 28, 2020.
You asked the Plan to reimburse you for the full amount you paid for the ankle foot orthosis. You say that you were told the orthosis was covered so you want to be reimbursed the full amount you paid. The Plan denied your request. The Plan says they will pay the remainder of the Medicare allowable rate for an ankle foot orthosis minus the coinsurance.
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 20% coinsurance for Prosthetic devices and related supplies. You have been asked to pay 20% coinsurance for the ankle foot orthosis. The ankle foot orthosis falls within the Prosthetic devices and related supplies benefit category. The Plan does not have to reimburse the cost over the Medicare allowable amount. This means that you have been asked to pay the correct amount based on your contract with the Plan. The 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 reimburse you for the full amount you paid for the ankle foot orthosis purchased on April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the deep sedation/general anesthesia provided on January 15, 2021.
You asked the Plan to pay for the deep sedation/general anesthesia. You say that there were no in-network providers available in your area. The Plan denied your request. The Plan says that sedation is only covered when the enrollee needs a lot of dental work done on the same day, four or more teeth pulled, or the enrollee is nervous about their treatment and a different drug has been tried and failed to help the enrollee relax during treatment.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the Plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the deep sedation/general anesthesia by a contract provider. The file does not show that the Plan provided notice that the deep sedation/general anesthesia would not be covered. Under Medicare rules, this means the deep sedation/general anesthesia is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the deep sedation/general anesthesia provided on January 15, 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 pay for the topical application of fluoride varnish (D1206) or pay more for the periodontal maintenance (D4910) provided on March 12, 2021.
You asked the Plan to pay for the topical application of fluoride varnish and to pay more for the periodontal maintenance. You say that you were reimbursed 100% of your dental claim in 2020. You also say that in 2021 you maintain the same Medicare plan coverage, but the Plan considers the same dental provider as out-of-network, resulting in a reduced benefit of 50%. The Plan denied your request. The Plan says the topical application of fluoride varnish is not a covered benefit. The Plan also says that a 50% coinsurance was applied correctly for the periodontal maintenance.
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, topical application of fluoride varnish is not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for the periodontal maintenance. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) or pay more for the periodontal maintenance (D4910) provided on March 12, 2021.
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 these services are medically necessary. The Plan
denied your request. The Plan says that your medical condition requires further evaluation and treatment in the
acute care hospital.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care.
You were admitted for coronary artery bypass grafting, respiratory failure and a pressure ulcer. 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. You do require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.
You asked the Plan to pre-approve eight (8) additional PT visits. You say that this patient has a degenerative disease and greatly benefits from exercising with a physical therapist in person as it could be a risk for her to perform some exercises at home on her own. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity of the PT services in question or that the member meets Medicare criteria.
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 eight (8) additional PT 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy 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 by or under the supervision of a therapist. The enrollee has been given two (2) more visits of therapy to ensure competence in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete series x-ray (D0210) and the 4-surface fillings (D2335 x
3) provided from September 15, 2020, to October 2, 2020.
You asked the Plan to pay for the complete series x-ray and the 4-surface fillings. You say that you were never
advised on your plan benefits being specific to certain things being covered. You say that you received a bill
for $1,000. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says
that the complete series x-ray is not listed as a covered service. The Plan says that fillings are not covered
services either.
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 complete
series x-ray and the 4-surface fillings when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the complete series x-ray and the 4-surface fillings have been met. Specifically, the Plan did not
provide evidence that the enrollee was informed that these services would be covered. Therefore, we decided
that the Plan has to pay for the complete series x-ray (D0210) and the 4-surface fillings (D2335 x 3) provided
from September 15, 2020, to October 2, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional wheelchair accessories (E1399, K0108x2).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not coded correctly.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve additional wheelchair accessories (E1399, K0108x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, binaural (V5261), hearing screening (V5008), dispensing fee binaural (V5160), and hearing aid or assistive listening device/supplies/accessories (V5267) provided October 16, 2020.
You asked the Plan to pay for the hearing aids and screening. You say that you would like the services covered. The Plan denied your request. The Plan says the services were provided by a non-participating provider without prior authorization and therefore not eligible for coverage.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and screenings only when received from a participating provider.
We looked at the file and the Plan's rules. In this case the hearing aids services were provided by a nonparticipating
provider. We found no exception that would require the Plan to pay for these services. Based on
this information, we decided that the Plan's rules for coverage of the hearing aids and screening have not been
met. Therefore, we decided that the Plan does not have to pay for the hearing aid, digital, binaural (V5261),
hearing screening (V5008), dispensing fee binaural (V5160), and hearing aid or assistive listening
device/supplies/accessories (V5267) provided October 16, 2020.
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 transfer to the LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee has not completed the full course of care in the hospital and can stay in the hospital to finish the treatments.
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 are not available at the acute care hospital where he 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS device, pneumatic compression vasopneumatic device and multivitamin injections provided on February 2, 2021.
You asked the Plan to pay for the TENS device, pneumatic compression vasopneumatic device and multivitamin injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the TENS device is not a Medicare covered benefit with the available information, the vasopneumatic is only covered for the treatment of chronic venous insufficiency with venous stasis ulcers and vitamin injections into the nerve and muscular structures are not a Medicare covered 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 pay for the TENS device, pneumatic compression vasopneumatic device and multivitamin injections. Our reviewer says that the member does not meet criteria for the TENS device. The documentation does not reveal objective progress notes with evidence of failure of other treatments. The documentation does not reveal what medications the member has tried for their pain, failure of physical therapy, or that the TENS unit is being used to treat chronic intractable pain other than low back pain. Our physician reviewer found the criteria for a vasopneumatic device has not been met. There is no evidence that this is being used for reduction of edema after acute injury; lymphedema of an extremity; or education on the use of a lymphedema pump for home use. Our physician reviewer additionally found that vitamin injections are not medically necessary. The documentation does not reveal objective lab evidence of a vitamin deficiency that requires the vitamin injections. The request exceeds the patient's medical need. 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 TENS device, pneumatic compression vasopneumatic device and multivitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for the TENS device, pneumatic compression vasopneumatic device and multivitamin injections provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (36415,80053,
83036) provided on March 25, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
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
copayment for laboratory services provided at an outpatient hospital.
You have been asked to pay a $14.10 copayment for the laboratory services provided at an outpatient hospital.
This amount is less than the applicable copayment for this service. 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 (36415,80053, 83036) provided on March 25, 2021.