Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic radiographic images (D0330), bitewing radiographic images (D0274), a teeth cleaning (D1110), intraoral periapical radiographic images (D0220, D0230 x3), and oral hygiene instructions (D1330) provided on March 22, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, panoramic radiographic images, bitewing radiographic images, a teeth cleaning, intraoral periapical radiographic images, and oral hygiene instructions. You say that you were not aware that the provider was out-of-network and were told the services would be covered. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider. Intraoral periapical radiographic images, and oral hygiene instructions are not covered benefits. 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, panoramic radiographic images, bitewing radiographic images, a teeth cleaning, intraoral periapical radiographic images, and oral hygiene instructions have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Additionally, intraoral periapical radiographic images, and oral hygiene instructions are not covered benefits. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic radiographic images (D0330), bitewing radiographic images (D0274), a teeth cleaning (D1110), intraoral periapical radiographic images (D0220, D0230 x3), and oral hygiene instructions (D1330) provided on March 22, 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 you need occupational and physical therapy to 
optimize level of function. The Plan denied your request. The Plan says that you can safely receive the services 
you need in other settings. 
 
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 bilateral knee replacement.

Your 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. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0481) provided on March 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a drug test. You say that you would like reconsideration of the denied claim. You also say that you thought you were enrolled in a Plan that accepted your primary care doctor as well as your pain management doctor. The Plan denied your request. The Plan says services were provided by an out-of-network 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a drug test (G0481) provided on March 15, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories (E1028, E0955, E1226, E0973, K0823, E2365) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a face-to-face evaluation.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not support a need for this wheelchair. There is no indication that the enrollee is unable to ambulate, and that he could not use a manual wheelchair if needed. The documentation does not indicate a need for supplemental oxygen, upper extremity pain, or that he is an amputee. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories (E1028, E0955, E1226, E0973, K0823, E2365) for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0425) provided on January 14, 2021.
You asked the Plan to pay for ambulance services. You say that this service was provided to transfer the enrollee to the nearest facility that could treat him. The Plan denied your request. The Plan says that this was the second leg of a trip with an intermediate stop that must be billed and paid as a single ambulance service.
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. The Plan has not submitted a claim or remittance showing that the first trip was billed by the same provider. The records do not indicate that the facility-to-facility transfer was provided by the same provider as a continuation of the enrollee's earlier transportation to the emergency room. Therefore, we decided that the Plan has to pay for ambulance services (A0425) provided on January 14, 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: 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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex-walk system (L5981) and multiaxial ankle (L5968).
You asked the Plan to pre-approve a Flex-walk system and multiaxial ankle. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested items are not medically necessary.
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 a Flex-walk system and multiaxial ankle. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the records do not support that the enrollee meets the criteria for the requested foot components. Notes describe that the enrollee's requested foot is the same as the current foot that was supplied in October 2020, so it is less than a year and the supplied foot is still under warranty and hence a replacement cannot be covered. 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 Flex-walk system and multiaxial ankle have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flex-walk system (L5981) and multiaxial ankle (L5968).
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 care needs can be met in the skilled nursing facility 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. 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 congestive heart failure, bacteremia and upper extremity thrombophlebitis. Your 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that it is medically necessary for this screening. The Plan denied your request. The Plan says the coverage criteria for this service have not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. We find that the enrollee does not have a history of tobacco smoking of at least 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral arm and subaxillary lipectomies.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is determined to be cosmetic.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee underwent gastric bypass surgery in March 2020. The provided records state that the enrollee has lipodystrophy and heaviness in the arms. The record and photographs provided do not support that there is candidiasis, intertrigo or tissue necrosis involving the arms that is unresponsive to oral or topical medication. The elements of the coverage criteria 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral arm and subaxillary lipectomies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the lumbar spine (72131).
You asked the Plan to pre-approve the CT scan of the lumbar spine. You say that this request is medically necessary. The Plan denied your request. The Plan says a second imaging service is not medically necessary at this time.
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 the CT scan of the lumbar spine. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the review indicates that there is no specific clinical rationale for the requested CT scan. The results of the first detailed picture study may be sufficient. The records show that the same or similar study has already been approved. Further imaging can only be approved when additional tests are needed to direct care. No new information related to the previous study was provided for review. The requested CT scan of the lumbar spine 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 CT scan of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the lumbar spine (72131).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for two (2) breast prostheses (L8000, L8030) provided on March 2, 2021.
You asked the Plan to waive the coinsurance for breast prostheses. You say that you are being billed by the provider. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 each durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for each breast prosthesis. The allowed amount of the claim is $524.17, resulting in a coinsurance obligation of $104.83. The EOC confirms 20% is the required coinsurance for this service. A breast prosthesis falls within the durable medical equipment (DME) and related supplies 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 two (2) breast prostheses (L8000, L8030) provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen system purchased October 7, 2019.
You asked the Plan to pay for the portable oxygen system. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says additional documentation was required before this service was received.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. In this case, you specifically indicated that this item was necessary for a trip you were going on. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the portable oxygen system purchased October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist visit provided on February 15, 2021.
You asked the Plan to waive the copay for the services provided. You say that the visit was for the results of your preventive visit. The Plan denied your request. The Plan says the copay is your financial responsibility.
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 copay for specialist services. You have been asked to pay a $40 copay for specialist services. The services fall within the physician 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 copay for the specialist visit provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received February 25, 2021.
You asked the Plan to pay for the dental services. You say that the requested dental services were necessary. The Plan denied your request. The Plan says your dental rider was not active until March 1, 2021.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your supplemental dental benefit was not active with the Plan until March 1, 2021. You were not eligible to receive these services prior to the start of coverage. Therefore, we decided that the Plan does not have to pay for the dental services received February 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 services are medically necessary. The Plan denied your request. The Plan says you do not meet the guidelines for long term acute care services. You can safely receive this care in another setting, such as a skilled nursing 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 in this case the enrollee was admitted following suffering a crush injury when struck by a tractor and receiving multiple injuries. He continues to gradually improve. 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 but that would be available at the LTACH facility. The elements of the coverage rules 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 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.