Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is a fall risk, and does not have the strength to get up by herself. The Plan denied your request. The Plan says the enrollee is medically stable and has no skilled nursing or therapy needs.
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 services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee required varying assist with transfers, and was independent with bed mobility. The enrollee required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem tartrate for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem tartrate for the
enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehab needs to improve strength, endurance, mobility, and activities of daily living. The Plan denied your request. The Plan says the enrollee is medically stable and does not require a more intensive rehab.
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 physician reviewer found that the enrollee was admitted to acute care for a fall and right-sided weakness. Findings on workup included acute-on-chronic subdural hematoma. The enrollee underwent left burr hole decompression, and now there are no signs of toxicity. The enrollee is afebrile. 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 is at moderate to minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attachment abutement, lower arch (D6052).
You asked the Plan to pre-approve attachment abutement, lower arch. You say that you are requesting
reconsideration and the records should support necessity of the services. The Plan denied your request. The
Plan says the requested service is not listed as 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. Services not listed on the
dental benefits chart are not covered by the plan.
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 pre-approve
attachment abutement, lower arch (D6052).
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 enrollee needs to regain strength in the IRF setting. The Plan denied your request. The Plan says the enrollee's condition is stable and she does not need intensive therapy.
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 complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve home health skilled nursing. You say that you need skilled nursing to help you with your medication due to your conditions. The Plan denied your request. The Plan says the denial of authorization for home health skilled nursing care is correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health skilled nursing. Our reviewer says that you do not meet the Medicare criteria for the requested home health care services. Our physician reviewer found there are no identified ongoing skilled nursing needs. There is no history of recent hospitalization or unaddressed medical issues. Education has already been provided to you in terms of your condition and medication administration, and you live with your family so would be expected to have caregiver assistance available if needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no high-level medical evidence that the use of bone marrow aspirate is supported in this case.
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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support a request for bone marrow aspirate for the approved surgical procedure. There is no compelling rationale presented or circumstances noted to support medical necessity of bone marrow aspiration in conjunction with lumbar surgery. There is a lack of large volume, long-term peer reviewed outcome studies to support the use of bone marrow aspirate for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #3.
You asked the Plan to pre-approve the dental service. You say that tooth # 3 has deep caries, approaching the bone. The Plan denied your request. The Plan says the tooth will not last long because there is a cavity below the bone.
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 crown for tooth # 3 does not have a successful long-term prognosis. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 16, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says out-of-network services require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health testing (96116, 96138, 96139, 96132, 96133).
You asked the Plan to pre-approve the behavioral health testing. You say that the requested services are medically necessary. The Plan denied your request. The Plan says this level of service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. No medical records were provided for review. Based on this information, we decided that Medicare rules for coverage of the behavioral health testing have not been met. Therefore, we decided that the Plan does not have to pre-approve behavioral health testing (96116, 96138, 96139, 96132, 96133).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out-of-network provider at the in-network benefit level.
You asked the Plan to pre-approve the services at the in-network benefit level. The Plan denied your request. The Plan says the services are available in-network.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 40% coinsurance for out-of-network specialist services. The requested specialist care is available within the plan's network of providers. This means the plan is not required to make an in-network exception for the requested out-of-network services. There is a 40% coinsurance for the out-of-network specialist services. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pre-approve services with an out-of-network provider at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one additional unit of medial branch block injection for the enrollee.
You asked the Plan to pre-approve the additional level of injection. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare only allows two joints to be injected per session in each region.
The Plan must follow Medicare rules. Medicare rules say that only two levels of medial branch block are covered per session. The plan has already approved the first two levels of the injection. The third level cannot be approved. Based on this information, we decided that Medicare rules for coverage of the additional level of injection have not been met. Therefore, we decided that the Plan does not have to pre-approve one additional unit of medial branch block injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmoscopy providedon October 4, 2019You asked the Plan to pay for the ophthalmoscopy. You say that it was beyond your ability to obtain the authorization because the doctordoes not know which patients she will be seeing since sheis assigned to a facility and given a chart of patients in need of services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an ophthalmoscopy provided on October 4, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveModafinil tablets.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescriptiondrug benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveModafinil tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on September 18, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you were told that you would not owe a copayment.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 $225 copayment for advanced imaging services. You have been asked to pay the allowed amount of $197.98, which is less than the $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment fora CT scan provided on September 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound compression systems provided on August 22, 2019 and August 30, 2019.You asked the Plan to waive the copayments forwound compression systems. You say that you disagree with the outpatient surgery charges.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 $375 copayment for surgery services provided in an outpatient hospital facility.You received wound compression systems on August 22, 2019 and August 30, 2019. Wound compression systems are considered outpatient surgical procedures. Therefore, you are responsible to pay the total allowed amount of $258.68, which is less than the total copayment amount.  You have been asked to pay $258.68 for wound compression systems. Wound compression systems fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments forwound compression systems provided on August 22, 2019 and August 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveTestopel pellets.You asked the Plan to pre-approveTestopel pellets. The Plandenied your request. The Plan says that you have not failed transdermal administration, or why such a method is contraindicated.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 Testopel pellets. Our physician reviewer found that you have hypogonadism. You have been successfully treated with insertion of 6 testosterone pellets every 3 months since June 26, 2018. Testosterone replacement with testosterone pellets is both appropriate and indicated for male hypogonadism. You have been effectively treated with testosterone pellets. Therefore, the requested drug is medically reasonable and 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 Testopel pellets have been met. Therefore, we decided that the Plan has to pre-approveTestopel pellets.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora SNF stay from March 1, 2019 to April 30, 2019.You asked the Plan to waive the copayment fora SNF stay. You say that you were not informed that the enrollee would owe a copayment.The Plandenied your request. The Plan says the claims were processed correctly,and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $150 copayment for days 21 -100 for SNF care. The enrollee had a SNF stay from March 1, 2019 to April 30, 2019. The enrollee is not being charged for days 1-20 (March 1, 2019 to March 20, 2019). The enrollee is responsible to pay $4,470.90, which is less than the total copayment amount. The enrollee has been asked to pay$4,470.90 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora SNF stay  from March 1, 2019 to April 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on August 15, 2019.You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with thePlan 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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on August 15, 2019.