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

We decided that the Plan does not have to pre-approve the partial upper denture (D5213) and the partial lower denture (D5214).
You asked the Plan to pre-approve the dental items. You say that you need new dentures. You also say that you need replacement dentures. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 frequency limit for dentures has been exceeded. The Evidence of Coverage says dentures are covered once every 5 years and replacement of dentures less than 5 years of age does not meet the criteria for pre-authorization for a new denture. The record shows that the Plan paid for dentures that you received on September 11, 2020. Therefore, we decided that the Plan does not have to pre-approve the partial upper denture (D5213) and the partial lower denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical complexity and care requirements make her a very high risk for returning to the STACH and that her medical issues can be safely managed in a LTACH as she continues to make improvements. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for LTACH admission.
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 has a history of diabetes, and was admitted to the acute care hospital on November 10, 2020 with respiratory failure due to COVID-19 and pneumonia. The enrollee has been treated with oxygen, BiPAP, IV antibiotics, steroids, Remdesivir, and convalescent plasma. On December 9, 2020 the enrollee was on an FiO2 of 100 via BiPAP with the plan to wean oxygen as tolerated. Oral steroids were being tapered. Antibiotics were being started for multifocal pneumonia, and a 500 mL bolus was ordered. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care and the acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable and appropriate for the diagnosis and condition of the enrollee at this time.
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 LTACH 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 that the enrollee meets CMS LTACH admission criteria and his ongoing medical care warrants a LTACH level of care to achieve a safe and sustainable discharge per CMS guidelines. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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 has a history of hypertension, and was admitted to the acute care hospital on November 24, 2020 with respiratory failure due to Covid-19 pneumonitis and Acute respiratory distress syndrome (ARDS). The enrollee has been treated with oxygen, BiPAP, Remdesivir, convalescent plasma, and steroids. On December 7, 2020, the enrollee was on high-flow nasal cannula documented to be stable and improving. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable and appropriate for the diagnosis and condition of the enrollee at this time.
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000 x 2).
You asked the Plan to pre-approve foot orthotics. You say that orthotics are necessary as you have difficulty walking and have pain in your feet. The Plan denied your request. The Plan says that foot orthotics are not a covered benefit under your contractual policy for your condition.
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 pre-approve foot orthotics (L3000 x 2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinsertion of a permanent leadless pacemaker.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthis request cannot be approved.The Plan must follow Medicare rules. The rules say that leadless pacemakers are only covered as part of an ongoing FDA-approved post-approval study.The requested procedure can only be approved as part of a clinical study. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinsertion of a permanent leadless pacemaker.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided from May 1, 2019 to May 4, 2019.You asked the Plan to pay forthe SNF services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 the SNF services are not supported in the medical record. Specifically, the procedure code is inconsistent with the modifier used. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided from May 1, 2019 to May 4, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveincontinence supplies.You asked the Planto pre-approveincontinence supplies. You say that itis imperative that you get this approval, as the equipment is used at night.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plandoes not haveto pre-approveincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on February 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.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 issuein 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 forphysician services provided on February 6, 2020 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information did not indicate a post-treatment assessment of percentage of pain relief.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not achieve significant pain relief from the prior epidural steroid injection. This does not meet the criteria of the LCD, and therefore, the request is deemed not medically or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pontic (D6245) for tooth # 30 and retainer crowns (D6740) for teeth # 29 and 31.You asked the Plan to pre-approvethe fixed bridge. You say that a denture is temporary but a bridge is permanent. You also say that your dentist advised it would be a lot of metal in your mouth for 1 tooth.The Plan denied your request. The Plan says the requested codes are listed as covered. The Plan says they are only covered when documentation supports a specific medical condition that precludes theuse of removable prosthesis. The Plan also says that the medical necessity criteria has not been met.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 Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the fixed bridge is not medically necessary. Our physician reviewer found based on the provided documentation provided, fixed bridges are considered for coverage to replace a single maxillary anterior tooth or two mandibular anterior teeth. The reviewer found that tooth # 30 is a posterior tooth and the patient has adequate masticatory function. Therefore, the reviewer found that the fixed bridge is not medically reasonable and necessary.
Appeal type: Imaging
Decision: Unfavorable

We decided that thePlan does not have to pre-approvea whole body PET/CT scan.You asked the Plan to pre-approvea whole body PET/CT scan. You say that the requested whole body PET/CT scan is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested whole body PET/CT scan.The Plan must follow Medicare rules. Medicare rules say that PET 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 whole body PET/CT scan. Our reviewer says that the enrollee does not meet criteria for the requested whole body PET/CT scan. Our physician reviewer found the enrollee is with weight loss and suspected malignancy. The documentation provided demonstrates that malignancy is not strongly suspected. The requested whole body PET/CT scan is not a screening modality and is not medically necessary in this case.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 whole body PET/CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea whole body PET/CT scan
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are notcovered. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The requested Vertiflex Superion spacer is considered experimental, as more research is needed to safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion spacer. Local Coverage Determination (LCD) L34006 referenced by the Plan is retired and was not used in the determination
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the coinsurance  forradiation  therapy  provided  by a participating  provider on January  6, 2020, to January  10, 2020.You asked the  Plan to waive  the coinsurance  forradiation  therapy.  You  say that the  member  is  very  upset  about this  issue.The  Plan  denied  your  request.  The  Plan  says the correct  coinsurance  has been  applied.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 20% coinsurance  for  Medicare  Part B prescription  drugs. The  enrollee  has  been asked to pay a 20% coinsurance  of the  allowed  amount  is $3,378.66. The  total  amount you  are being  asked to pay is  $675.74 ($3,378.66 x 20% = $675.74) for  radiation  therapy.  Radiation  therapy falls  within  the  Medicare  Part B prescription  drugs  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 coinsurance  forradiation  therapy  provided  by a participating  provider on January  6, 2020, to January  10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveacute  inpatient  rehabilitation  facility (IRF)  admission and services.You asked the  Plan to pre-approveIRF care. You  say that the  services  are medically  necessary.The  Plan denied  your  request.  The  Plan  says the  services  are 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 medically  necessary.  Our physician  reviewer  found  the  enrollee  underwent  right  total hip  arthroplasty  on December  1, 2020. The  physical  therapy  note  dated December  7, 2020 states  she needs modified  assist  to sit  up and minimum  assist  to stand up and  lie  down. She could  only  take a few  steps due to pain.  She does not require  the intensity  of  services  provided  at an IRF. Specifically,  the  enrollee  is  not shown  to be able  to tolerate  15 hours  per week of rehabilitative  services  with  regular  physician  evaluation.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-approveacute  inpatient  rehabilitation  facility  (IRF)  admission  and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital services you received from October 14, 2017, to October 16, 2017.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you shouldn't have to pay this copayment because you received inadequate care.The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment per day for days 1-5 for each admission for inpatient hospital care. You have been asked to pay a total of $500 ($250 per day, for two days) for the inpatient hospital services.This copayment applies regardless of your satisfaction with the care you received. 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 forinpatient hospital services you received from October 14, 2017, to October 16, 2017.Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the copayment  fora specialist  visit  provided  on April  24, 2020.You asked the  Plan to waive  the copayment  fora specialist  visit.  You  say that you  should  only  owe a $5 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 $50 copayment  for  services  obtained  by a specialist. You  have  been asked to pay the  allowed  amount  of  $11.41, which  is less  than  the  $50 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 yourcontract  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 specialist  visit  provided  on April  24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 12, 2020, to August 14, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that your hip detached two weeks after surgery so you had to return to the hospital. You feel that because it was not your fault the hip detached you should not be responsible for the 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 $395 copayment for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from August 12, 2020, to August 14, 2020. Therefore, you are responsible to pay a $395 copayment for days 1-4 (August 12, 2020, to August 13, 2020). $395 (copayment) x 2 (inpatient days) = $790. You have been asked to pay the total copayment amount of $790 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care 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 inpatient hospital care from August 12, 2020, to August 14, 2020.