Persius/hicric huggingface dataset:
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 for IRF care 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, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly MODERATE 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the core buildup, including any pins when required, porcelain or ceramic crown, and inhalation of nitrous oxide/analgesia provided on October 2, 2019.You asked the Plan to waive the coinsurance for the core buildup, crown, and inhalation of nitrous oxide/analgesia. You say that several temporary crowns fell out. You also say that you did not go for crown placement after this because you had lost confidence in this provider.The Plan denied your request. The Plan says they cannot approve payment of your contractual obligation due to dissatisfaction of the service. The Plan says that you were charged correctly for these services.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 Evidence of Coverage clearly states that you must pay 50% coinsurance for comprehensive dental services that are received in-network.Therefore, we decided that the Plan does not have to waive the coinsurance for the core buildup, including any pins when required,porcelain or ceramic crown, and inhalation of nitrous oxide/analgesia provided on October 2, 2019.
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 above 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 services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (denosumab).You asked the Plan to pre-approvethe Xgeva treatments. You say that the enrollee has been receiving this drug due to findings of vertebreal osteolytic lesions. This is necessary to heal the bone and to prevent further lesions.The Plan denied your request. The Plan says this is not covered for non-solid tumors like those in lymphoma.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Xgeva treatments. Our reviewer says that the requested use of Xgeva is not considered reasonable and necessary. Our physician reviewer found the enrollee has diffuse large B-cell lymphoma with paratesticular involvement with bone lesions and is undergoing chemotherapy. The use of Xgeva is not FDA approved for use in bone lesions associated with lymphoma. A search of the literature did not find any articles to support use of denosumab in lymphoma. 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 Xgeva treatments have not been met.Therefore, we decided that the Plan does not have to pre-approveXgeva (denosumab).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea second home ventilator.You asked the Plan to pre-approvea Trilogy ventilator for the enrollee's wheelchair.You say that the enrolleecannot transfer the bedside ventilator so the enrollee needsthe second ventilator in order to not bebedbound.The Plan denied your request. The Plan says that a second ventilator is a convenience item.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 Trilogy ventilator for the enrollee's wheelchair.Our physician reviewer found asecond ventilator is considered reasonable and medically necessary for this enrollee. The enrollee has chronic respiratory failure related to generalized neuromuscular disease and severe restrictive lung disease.  The enrollee uses the ventilator at least 16 hours per day, and is unable to transfer the ventilator to the wheelchair because of weakness.  A second ventilator is necessary for mobility within the home, and is therefore not considered a convenience item. It appears that the second ventilator was previously approved. The denial is overturned.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 Trilogy ventilator for the enrollee's wheelchairhave been met.Therefore, we decided that the Plan has to pre-approvethesecond home ventilator.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 custom breast prosthesis (L8035).
You asked the Plan to pre-approve custom breast prosthesis. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of custom breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve custom breast prosthesis (L8035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).You asked the Plan to pre-approve the semi-electric hospital bed. You say that say the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says the reasonable useful lifetime for DME is 5 years and replacement should not occur before 5 years.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The records show you were provided with a semi-electric hospital bed in November, 2017 and the notes do not indicate that the existing bed is damaged and needs repair. Based on this information, we decided that Medicare rules for coverage of the semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. Yousay that you feel that you would benefit from daily skilled therapy in the SNF.The Plan denied your request. The Plan says you do not require daily skilled therapy to maintain your level of function or prevent deterioration. Further improvement is alsonot likely expected with daily skilled therapy over less than daily services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was treated in the hospital from 1/2 until 1/15 for heart failure and atrial fibrillation and then discharged to IRF. SNF was requested but she was discharged home on 2/12 with home health. The enrollee is currently ambulating 10 feet in the parallel bars with minimal assist, requires moderate assist with sit to stand, and supervision with manual wheelchair for household distances. Based on available records, the patient does not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. While he may benefit from continuing PT and OT, the records do not support the need for daily therapy. The enrollee is at/near his baseline level of function.
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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracapsular cataract removal and posterior chamber intraocular lens provided on September 10, 2019.You asked the Plan to pay for the extracapsular cataract removal and posterior chamber intraocular lens. You say that this procedure was not related to the enrollee's terminal illness. You also say that per Medicare guidelines, any procedure not related to the terminal illness is covered by the Plan.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the extracapsular cataract removal and posterior chamber intraocular lens provided on September 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram provided on August 7, 2019.You asked the Plan to waive the copayment forthe electrocardiogram. You say that the echocardiogram was not done at an outpatient hospital. The Plan denied your request. The Plan says you have been charged 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 a $100 copayment for each Medicare-covered diagnostic procedures and tests for services in an in-network outpatient hospital facility. You have been asked to pay a $100 copayment for the electrocardiogram. The electrocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by an outpatient hospital.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 forthe electrocardiogram provided on August 7, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the service is necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. Our reviewer says that the service is medically necessary. Our physician reviewer found the rationale for the requested CT of the abdomen and pelvis is not for the evaluation of local or distant metastasis but rather to evaluate the upper urinary tracts and ureters due to the common instability of uroepithelium in cases of bladder cancer. This approach is reasonable and appropriate for the enrollee's age and bladder tumor history. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the abdomen and pelvis have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).
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 complete mandibular denture and complete maxillary denture provided on July 1, 2019.You asked the Plan to pay for the complete mandibular and maxillary dentures. You say that the only reason you went to this provider is because your spouse was told that this provider accepted your insurance plan.The Plan denied your request. The Plan says this provider is non-contracted with your plan. The Plan also says that no benefits are available for procedures performed by out-of-network providers.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay for the complete mandibular denture and complete maxillary denture provided on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 11, 2019 to June 12, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 11, 2019 to June 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has successfully undergone Orthovisc injections in the past, is not currently a candidate for surgery, and would benefit from Orthovisc. The Plan denied your request. The Plan says the denial of authorization for Orthovisc is correct, because recent studies found that the use of Orthovisc is not helpful in treating knee pain.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Orthovisc. Our physician reviewer found the record submitted does not include documentation as to the effect of previous injection therapy. Recent literature does not support the use of viscosupplementation for knee pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of Orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 7, 2019.You asked the Plan to pay for the dental service. You say that this dentist was previously paid in 2018 for this kind of service. You say that the provider is listed as in network. You also say that the provider advised he has not opted out of Medicare.The Plan denied your request. The Plan says dental services received from providers that have opted out of Medicare are not covered or payable.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.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to lower the copayment for emergency services received outside of the United States on October 1, 2019.
You asked the Plan to lower the copayment for emergency services received outside of the United States. You say that your copayment should only be $75 dollars. The Plan denied your request. The Plan says this service processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 copayment for emergency services outside the U.S. You have been asked to pay a $500 copayment for emergency services received outside of the United States. 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 lower the copayment for emergency services received outside of the United States on October 1, 2019.