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

We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 9, 2021.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says prior authorization is required for all non-contracted providers.
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 service 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 subsequent nursing facility care provided on March 9, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a humidifier billed for services provided on September 10, 2020.
You asked the Plan to pay for the humidifier. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a humidifier billed for services provided on September 10, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide visits, 4 hours per week.
You asked the Plan to pre-approve home health aide visits. You say that you have mobility issues and other issues that require a home health aide. The Plan denied your request. The Plan says you do not have a complex need for skilled home health aide services. The Plan also says that your needs can be met with a lesser service.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide visits have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health aide visits, 4 hours per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 4 and 19.
You asked the Plan to pre-approve the dental services. You say that the crowns for teeth # 4 and 19 are medically necessary. The Plan denied your request. The Plan says there is a maximum coverage limit of $1,000 for routine dental services. The Plan also says that the maximum coverage 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 and the services are listed as covered, the maximum coverage limit has been reached. The record shows that the Plan paid $ $107 for dental services received on August 5, 2021, and $54 for dental service received on September 16, 2021. Additionally, the Plan approved crowns for teeth $ 1 and 3 in the amount of $839. $107 + $54 + $839 = $1,000. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 4 and 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 11, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 11, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric care from November 11, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 11, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 11, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 11, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 11, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on March 29, 2021, and March 30, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that The Plan denied your request. The Plan says the diagnosis codes are not appropriate for this claim.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We looked at the file and Medicare rules. The diagnosis codes used in this claim were: Z79.4 - long term current use of insulin Z99.2 - dependence on renal dialysis Both of these codes are considered exempt as diagnosis codes that are Present on Admission (POA). Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on March 29, 2021, and March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fixed wing air transportation (A0430, A0435).
You asked the Plan to pre-approve fixed wing air transportation. You say that the services are medically
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 fixed wing air transportation. Our
reviewer says that the elements of the coverage criteria are not satisfied.
Our physician reviewer found the documentation does not support that the enrollee suffers from an illness or
injury that contraindicates transportation by any means other than ambulance. The documentation does not
support that the enrollee's condition is such that the time needed to transport a patient by ground, or the
instability of transportation by ground, would pose a threat to the enrollee's survival or seriously endanger the
enrollee's health. The enrollee is hemodynamically stable and should be able to tolerate ground transportation
to the nursing 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 fixed wing air transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve fixed wing air transportation (A0430, A0435).
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein of extremity (36475).
You asked the Plan to pre-approve endovenous ablation therapy of incompetent vein. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.
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 endovenous ablation therapy of incompetent vein. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that you are currently experiencing lifestyle limiting symptoms nor that there have been concerted efforts at conservative care; for example, having you refitted/prescribed for well-fitting compression stockings with instructions for their use. Additionally, coverage criteria require that your CEAP and venous severity scores are documented. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy of incompetent vein have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein of extremity (36475).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without contrast to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal.
We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without contrast to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on June 17, 2021.

You asked the Plan to pay for the dental service. You say that you were charged $456 for a full mouth debridement. You say that there was no debridement. You also say that you are going to changed dentists. The Plan denied your request. The Plan says a claim for a comprehensive oral evaluation, complete series x-ray, and full mouth debridement totaling $456. The Plan says that the full mouth debridement is not listed as a covered service.

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 full mouth debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on June 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you have no daily skilled nurse or therapist need.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) brain (including brain stem) provided June 7, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you had to have the service completed twice due to the initial one being done incorrectly. You should not be held responsible for things beyond your control. The Plan denied your request. The Plan says the 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 $270 copay for advanced imaging services for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay $270 copay for advanced imaging services for the diagnostic service. the diagnostic service 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 for the magnetic resonance imaging (MRI) brain (including brain stem) provided June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for
tooth #15.
You asked the Plan to pre-approve a crown. You say that a new crown is required for tooth #15, as there is an
open contact between teeth #14 and #15 which causes food to get stuck. The Plan denied your request. The
Plan says there is no documentation showing that there are any problems with the crown currently on tooth
#15. There is no documented fracture or decay. Crowns are not covered for cosmetic reasons or for closing
gaps.
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 a crown when
there is extensive decay or destruction of the tooth where the tooth cannot be fixed with only a filling.
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 crown. Our reviewer says that the
criteria for the requested crown are not met. Our physician reviewer found the stated reason for replacement in
this case is that there is a space that has developed between teeth #14 and #15 such that food is getting caught
in that area. The provided x-rays do not show any defect with the existing crown on either tooth despite the
history of food impaction. The Plan provides that crowns may be covered wen there is extensive decay or
destruction of the tooth where the tooth cannot be fixed with only a filling. Crowns for cosmetic reasons or for
closing gaps are not covered. Under the Plan provisions, there is no coverage for a replacement crown without
evidence of a defect (recurrent decay) of the existing crown. As there is no evidence of a defect or recurrent
decay, the Plan's criteria have not been met for the requested crown on tooth #15.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #15.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Injectafer (ferric carboxymaltose), 750 mg one time a week for 2 doses.
You asked the Plan to pre-approve Injectafer. You say that the drug is medically necessary. The Plan denied your request. The Plan says that that the criteria has not been met.
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 Injectafer. Our reviewer says that Injectafer (ferric carboxymaltose), 750 mg one time a week for 2 doses, is medically necessary. Our physician reviewer found the provided documentation indicates that your Ferritin levels are 19 which indicates that the you have an absolute iron deficiency. Therefore, the reviewer found that 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 Injectafer have been met. Specifically, the file shows that your ferratin levels indicate absolute iron deficiency. Therefore, we decided that the Plan has to pre-approve Injectafer (ferric carboxymaltose), 750 mg one time a week for 2 doses.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for services you received with a pain management specialist on August 2, 2021.
You asked the Plan to waive the copayment for the pain management specialist services. You say that you don't think you should have to pay an office visit copayment in addition to other cost sharing for the services received that day. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that on this date, you received several different services: you had an arthrocentesis procedure (for which the specialist copayment of $45 applied), you had an injection of methylprednisone (for which you were charged 20% coinsurance for Medicare Part B drugs), and you had a fluoroscopy (for which you were charged a $60 copayment for x-rays and ultrasounds).
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 $45
copayment for specialist visits. You have been asked to pay a $45 copayment for the pain management specialist services. This copayment applies in addition to the cost sharing amounts for the ancillary services 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 for services you received with a pain management specialist on August 2, 2021.