Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for physician's services provided in Guatemala from November 5, 2019 to November 26, 2019.

You asked the Plan to reimburse you for the physician's services. You say that while you were on an extended vacation in Guatemala, you received notification that the wrong skin lesions for melanoma on your back were removed by a dermatologist in the U.S. You say that you needed to see a doctor immediately for treatment of melanoma as this spreads fast. The Plan denied your request. The Plan says the services were available from providers within the Plan's network and it was not necessary or detrimental to your health to see an international provider.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  

We looked at the file, the Medicare rules and the Plan's rules. The file shows that the skin lesions were not due to an unforeseen illness or condition. The file shows that you did not contact the Plan to request authorization for these services. There is no evidence in the case file that your condition could be treated once you returned from vacation to your home within the Plan's service area. Therefore, we decided that the Plan does not have to reimburse you for physician's services provided in Guatemala from November 5, 2019 to November 26, 2019.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 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 the enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally given he needs minimal assist, no indication for IRF level of therapies. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: 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 the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 is currently undergoing treatment at an acute care hospital (ACH) following a posterior stroke. The enrollee was intubated/ventilated upon presentation. A thrombectomy was attempted, but was unsuccessful. The enrollee has since received a tracheotomy and a feeding tube. There is no evidence that ventilator weaning is being attempted, or that it is expected to be successful. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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 foot orthotics provided on December 6, 2019.You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Micra leadless pacemaker implant.
You asked the Plan to pre-approve the Micra leadless pacemaker implant. You say that the enrollee has bifascicular block, a-fib, and bradycardia. You say that the requested device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that leadless pacemakers are covered when performed in FDA approved studies. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. In this case, you asked the Plan to pre-approve the Micra leadless pacemaker implant. There is no evidence that the beneficiary is enrolled in any study or trail that meets the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve a Micra leadless pacemaker implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision care services provided on February 8, 2020 by an out-of-network provider.
You asked the Plan to pay for the vision care services. You say that you were not notified you could not use this provider. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 has network providers available who can provide 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 vision care services provided on February 8, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 the enrollee required contact guard assistance and minimal assistance with mobility. The documentation does not support that the enrollee requires an interdisciplinary approach to rehabilitation care. The enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay forthe open revision of an arteriovenous (AV) fistula for dialysis access provided on August 8, 2019.You asked the Planto pay forthe AV fistula revision procedure. You say that this was a medically necessary procedure that could not be delayed.The Plandenied your request. The Plansaysthatthis was not an emergency situation and no authorization for out of network care was obtained.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate revision to allow for dialysis access would lead to serious jeopardy to his or her health.Therefore, we decided that the Planhas to pay forthe open revision of an arteriovenous (AV) fistula for dialysis access provided on August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarthroscopy services (29823) provided on January 9, 2020.You asked the Plan to pay forthe arthroscopy services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement, extensive.We asked our coder 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 arthroscopy services. Our reviewer says that CPT code 29823 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation is not clear and does not support that extensive debridement was rendered.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthroscopy services have not been met.Therefore, we decided that the Plan does not have to pay forarthroscopy services (29823) provided on January 9, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier cost sharing exception for ipratropium bromide inhalation solution (J7644).You asked the Plan to pre-approvethe tier exception. You say that you would like reconsideration because this drug is too expensive.The Plan denied your request. The Plan says this medication is not eligible for a reduction to a lower copayment.The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Specifically, this drug falls under Medicare Part B coverage. Drugs covered under Medicare Part B are not eligible for tier cost sharing exceptions.Therefore, we decided that the Plan does not have to pre-approvea tier cost sharing exception for ipratropium bromide inhalation solution (J7644).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 26, 2019.You asked the Plan to waive the copayment for a specialist visit. You say that you have not seen the physician in 3 years.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each specialist visit.The medical records show that you had a specialist visit on November 26, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office 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 a specialist visit provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0150) complete series x-ray (D0210) and periodontal scaling and root planing (D4341x4) provided February 24, 2020. You asked the Plan to pay for the dental services. You say that the provider's office assured you that they accepted your dental insurance. You were not aware the appointment needed to be scheduled with a specific doctor to be covered. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider. 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 health plan contract specifically says that you pay 100% for out of network dental services. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0150) complete series x-ray (D0210) and periodontal scaling and root planing (D4341x4) provided February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental extraction (D7140x1) endodontic therapy, molar tooth (D3330x2) and endodontic therapy, anterior tooth (D3310) provided July 10, 2019 to November 4, 2019.
You asked the Plan to pay for the dental services. You say that you are asking for assistance in regard to the multiple root canals and extractions required. The Plan denied your request. The Plan says the second dental extraction and the 3 root canal treatments exceeds the plan 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. The extraction exceeds the benefit limitation of 1 extraction per year and root canal procedures are not listed as covered under the description of benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental extraction (D7140x1) endodontic therapy, molar tooth (D3330x2) and endodontic therapy, anterior tooth (D3310) provided July 10, 2019 to November 4, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the facet joint injection and related services provided on January 21, 2020.
You asked the Plan to pay for the facet joint injection procedure. You say that the provider's credentials have been provided to show that he is eligible to provide these services. The Plan denied your request. The Plan says that the provider is no longer credentialed or eligible for Medicare/Medicaid billing of 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. The documentation provided in the case file does not support that the treating physician had an inactive license on the date of service in question. Review of the website, the provider at issue in this case has an active medical license. No other documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the facet joint injection and related services provided on January 21, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH coverage criteria. The Plan denied your request. The Plan says admission to a LTACH is 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 considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an ACH for bilateral foot wounds. The enrolleehas undergone wound debridement and is receiving a prolonged course of antibiotics. The enrollee does not appear to be intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that continuation of care is necessary to treat the enrollee's medical condition. The Plan denied your request. The Plan says care can be provided by a doctor in the enrollee's network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.