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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia and a urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
The enrollee 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 enrollee 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 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve APC, MLH1, MSH2, MSH6, PMS2, and PTEN testing 81201, 81298, 81292, 81295.
You asked the Plan to pre-approve APC, MLH1, MSH2, MSH6, PMS2, and PTEN testing. You say that these tests are medically necessary. The Plan denied your request. The Plan says these tests are not likely to impact your treatment.
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 APC, MLH1, MSH2, MSH6, PMS2, and PTEN testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that you have breast cancer and have had benign colonic polyps removed. You will have another colonoscopy in five years. You do not have a known history of colon cancer. The medical record does not state how the requested services will impact your 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 APC, MLH1, MSH2, MSH6, PMS2, and PTEN testing have not been met. Therefore, we decided that the Plan does not have to pre-approve APC, MLH1, MSH2, MSH6, PMS2, and PTEN testing 81201, 81298, 81292, 81295.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture provided on December 9, 2020.
You asked the Plan to pay for the interim partial denture. You say that you were not aware that the interim partial denture was not a covered benefit. The Plan denied your request. The Plan says the interim partial denture is not a standard partial denture, and is meant to be a temporary appliance. The Plan also says that this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 interim partial denture provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the basic comprehensive audiometry
(92557) and tympanometry (92567) provided January 27, 2021.
You asked the Plan to waive the copayment for the diagnostic hearing services. You say that you were under
the impression that there was no charge for hearing exams. You received a bill that you don't think that you or
the Plan should have received. You sent the $34.91 by credit card over the phone. The Plan denied your
request. The Plan says this claim was processed with the correct copayment applied per the Evidence of
Coverage.
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 $40
copay for diagnostic exam to treat hearing and/or balance issues each calendar year.
You have been asked to pay $34.91 for the diagnostic hearing services. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. The diagnostic hearing services falls within the Hearing 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 the basic comprehensive audiometry (92557) and tympanometry (92567) provided January 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session (90837) provided on
October 14, 2020, by an OON provider.

You asked the Plan to pay for psychotherapy session. You say that you rendered treatment in good faith that
the service will get reimbursed. This service was provided with no adequate time frame to obtain authorization
for the service. The Plan denied your request. The Plan says enrollee's must receive their medical services from
an in-network provider with the exception being urgent or emergent services. Non-emergent services with noncontracted
providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for individual psychotherapy session (90837)
provided on October 14, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of erupted tooth requiring removal of bone (D7210), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia, each subsequent 15 minute increment (D9223), placement of intra-socket biological dressing to aid in hemostasis (D7922), periapical first radiographic image (D0220), panoramic radiographic image (D0330), and the detailed and extensive oral evaluation - problem focused (D0160) provided February 1, 2021, and February 2, 2021.

You asked the Plan to pay for the tooth extraction, deep sedation, placement of intra-socket biological dressing, periapical x-ray, panoramic x-ray, and detailed oral exam. You say that the care was urgently needed and should be covered. The Plan denied your request. The Plan says the services were not coded as urgent or emergent and services are not covered from a provider who has opted out of Medicare.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the extraction of erupted tooth requiring removal of bone (D7210), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia, each subsequent 15 minute increment (D9223), placement of intra-socket biological dressing to aid in hemostasis (D7922), periapical first radiographic image (D0220), panoramic radiographic image (D0330), and the detailed and extensive oral evaluation - problem focused (D0160) provided February 1, 2021, and February 2, 2021.

Your complaint about having issues with potentially poor information provided by the Plan about network providers 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or
therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria
for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the unspecified
preventive service (D1999) provided on February 8, 2021.

You asked the Plan to pay for the dental services. You say that you are disappointed with the dental plan. You
also say that the plan only paid $30 on a $115 bill. The Plan denied your request. The Plan says limited oral
evaluation is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a
covered service 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.

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 limited oral evaluation (D0140) and the unspecified preventive service (D1999) provided on February 8, 2021.

Your complaint about being disappointed with the dental plan 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 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 were admitted for surgical repair of a hip fracture after a fall. 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. 

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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.

You asked the Plan to pre-approve the MRI. You say that the enrollee has an elevated lifetime risk of developing breast cancer. You say that the enrollee has a strong familial medical history which includes breast cancer. The Plan denied your request. The Plan says the documentation provided does not show that the enrollee has a malignancy, positive axillary nodes, or that the enrollee is post op with scar tissue or any acute concerns.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the enrollee has a family history of breast cancer. MRI breasts was performed on May 14, 2020, revealing BI-RADS 1 negative on right and BI-RADS category 0 incomplete on left with recommendations to follow-up with ultrasound on left side to better evaluate a focal enhancement in left breast. Ultrasound the next day was inconclusive. Biopsy was performed on May 27, 2020, in left breast showing cyst material only. Follow-up MRI, bilateral breast, with CAD was recently requested. Based on the above history, there was no clear indication for repeat MRI. The abnormality found on MRI last year was biopsied and found to be a cyst. No other remaining areas required follow-up. Annual mammogram would be more appropriate in this clinical situation, according to current guidelines. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D4263), and extractions (D7140) provided on May 18, 2020.

You asked the Plan to pay for a bone replacement graft, and extractions. You say that the Plan should pay for the services because you have money left from your annual maximum. The Plan denied your request. The Plan says extractions are a covered benefit, but you have exceeded the frequency limit of one procedure per tooth per lifetime. The Plan also says that a bone replacement graft is not a covered benefit.

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 bone replacement graft, and extractions have not been met. Specifically, the record shows that you had exceeded the frequency limit for extractions per tooth prior to this service on July 11, 2019. Additionally, a bone replacement graft is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D4263), and extractions (D7140) provided on May 18, 2020.
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 requested LTACH services are a
medical necessity for the enrollee. 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 that the enrollee was admitted and found to have infectious endocarditis. The enrollee
requires long term antibiotics. The case file indicates that the enrollee is receiving acute care services that have
not been denied. The case file does not indicate that the enrollee requires acute care services that the enrollee is
not currently receiving but that would be available at the LTACH facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Medicare Part B prescription drug provided during
outpatient surgery on October 6, 2020.

You asked the Plan to pay for injection, methylprednisolone acetate, 40 mg (J1030). You say that the drug
should be covered with a 20% coinsurance. The Plan denied your request. The Plan says you are not being
billed for the copayment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code J1030 is not separately payable. This injection is integral to the covered surgical
procedure. Based on this information, we decided that Medicare rules for coverage of injection,
methylprednisolone acetate, 40 mg (J1030) have not been met. Therefore, we decided that the Plan does not
have to pay for the Medicare Part B prescription drug provided during outpatient surgery on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on September 22, 2020.

You asked the Plan to waive the coinsurance for the Part B drug. You say that the enrollee has already reached her 2020 out-of-pocket maximum. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% coinsurance for each Medicare-covered Part B drug. 

You have been asked to pay $197.92 which is 20% of the allowed amount for the Part B drug. The allowed amount is $989.62. ($989.62 x 20% = $197.92). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The record shows that at the time the claim was processed, you had met $3,494.32 of the $3,900 out-of-pocket maximum.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drug provided on September 22, 2020.