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

We decided that the Plan does not have to pay for the 13 extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided May 14, 2021.

You asked the Plan to pay for the surgical tooth extractions. You say that you feel the extractions should be covered because they are a side effect of your previous radiation treatment. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 13 extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided May 14, 2021.
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 IRF care to address his complex medical condition complicated by comorbidities which resulted in his function impairments and increased risk for medical instability. The Plan denied your request. The Plan says the requested IRF care 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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits (CPT code 99213) to be provided by out-of-network providers.
You asked the Plan to pre-approve the office visits. You say that this provider has the best reputation in the world, and it is close to your local area. The Plan denied your request. The Plan says the services can be provided by an in-network provider.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visits (CPT code 99213) to be provided by out-of-network providers.
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 meets criteria for and will benefit from IRF care. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional miles of routine transportation beyond the
Plan's 50-mile trip limit.
You asked the Plan to pre-approve routine transportation beyond the Plan's mileage limit. You say that it is
necessary for the enrollee to travel for treatment. The Plan denied your request. The Plan says the requested
transport exceeds the mileage limit for routine transportation.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving
distance.
We looked at your request, the records in the case file, and the rules. The requested transport in this case is
greater than the Plan's 50-mile limit. Based on this information, we decided that the Plan's rules for coverage
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve
additional miles of routine transportation beyond the Plan's 50-mile trip limit
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation beyond the Plan's 50-mile trip limit.
You asked the Plan to pre-approve routine transportation beyond the Plan's 50-mile trip limit. You say that you need to go to an appointment. The Plan denied your request. The Plan says the requested transport exceeds your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when it does not exceed 50 miles of driving distance for each one-
way trip.
We looked at your request, the records in the case file, and the rules. In this case the requested transport
exceeds 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine
transportation beyond the Plan's 50-mile trip limit
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 17, 2021, to May 21, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you would like the Plan to reduce the copayment applied to the claim. You also say you do not have any money to pay this copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $175 copayment per day, for days 1 to 7 for inpatient hospital care.
You have been asked to pay a $175 copayment per day for inpatient hospital care. The records show that you were inpatient for four (4) days ($175 x 4 days = $700). The EOC confirms that $175 per day is the required copayment for this service. 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 provided on May 17, 2021, to May 21, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compression sleeve/gloves with fingers (25-30mmHg) farrow, wrap, arm and hand (CPT code(s): S8429, S8420, E1399).
You asked the Plan to pre-approve the items. You say that this is due to breast cancer and you have to have your arms wrapped to your fingers with six (6) different wraps. You state this is covered by law because you had a mastectomy, and this is a lifelong condition that will never go away. The Plan denied your request. The Plan says the Medicare guidelines state medical supplies of an expendable nature, such as ace bandages, elastic stockings are not considered "durable" within the meaning of the definition. Medicare does not cover compression stockings.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Your request is not a covered benefit because these compression garments are non-reusable, non-rental items and are not being used to prevent joint contracture after a burn. Therefore, we decided that the Plan does not have to pre-approve the compression sleeve/gloves with fingers (25-30mmHg) farrow, wrap, arm and hand (CPT code(s): S8429, S8420, E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-contracted provider on March 20, 2020, to March 22, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the enrollee was diagnosed with Sepsis due to pneumonia. This diagnosis was clear and consistent throughout the medical record. The Plan denied your request. The Plan says this diagnosis did not qualify for reporting.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with A41.9 sepsis, unspecific organism and R65.20 severe sepsis without septic shock. 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 pay for inpatient hospital care. Our reviewer says that the enrollee had pneumonia. Our doctor found that the medical records did not support the billing of - A41.9 sepsis and R65.20 severe sepsis. Our physician reviewer found that the enrollee was treated with IV antibiotics and IV fluids with dramatic improvement on day two. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided by a non-contracted provider on March 20, 2020, to March 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.
You asked the Plan to pre-approve a bath/shower chair. You say that the requested device is for the enrollee's safety. You say that the enrollee feels better to have something to sit on while taking a shower. The Plan denied your request. The Plan says bath/shower chairs are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for budesonide.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the drug is not eligible for a tier exception.
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for a Part D tier exception. We looked at the file and Medicare rules. The requested drug, budesonide, is covered by Part B Medicare and not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for budesonide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.
You asked the Plan to pre-approve Xarelto. You say that this requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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-approve Xarelto.
Benefits for Xarelto 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office or other outpatient visit for the evaluation and management of a new patient (99203) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that your condition has not improved and an OON provider is necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the care you need.
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 items/services at issue in this appeal. Although you have seen some network providers, you have not exhausted all network providers at this time. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office or other outpatient visit for the evaluation and management of a new patient (99203) to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 14, 2021,
to June 15, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that enrollee's quality of health would have
resulted in serious injury had the enrollee not been admitted. The Plan denied your request. The Plan says the
enrollee did not meet interquel guidelines for inpatient level of care.
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 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 pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment were met in this case. Our
physician reviewer found the enrollee was admitted to telemetry, had a CT scan, which was negative, and the
enrollee's condition stabilized and improved.
We looked at this physician's review, the file, and Medicare rules. 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 the acute inpatient hospital care provided on June 14, 2021, to June 15, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fycompa.
You asked the Plan to pre-approve Fycompa. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical
benefit.
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 Fycompa.
Benefits for Fycompa 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan eye drops.
You asked the Plan to pre-approve Lumigan eye drops. You say that the enrollee has tried and failed other drugs but is stable on this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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-approve Lumigan eye drops.
Benefits for Lumigan eye drops 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 waive the copayment for inpatient hospital care provided on May 27, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told by different representatives that you would have no balance owed unless you stayed overnight. You also say you went in for a total hip replacement and left the same day to make sure you didn't have to pay any copayments. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $300 copayment each time you are admitted to an acute care hospital.
You have been asked to pay a $300 copayment for inpatient hospital care. The records show that there was an inpatient hospital authorization requested and approved for your hip replacement surgery. The EOC confirms that $300 is the required copayment for this service. 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 provided on May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the allograft rendered on December 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 20930 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 20930 (allograft, morselized, or placement of osteopromotive material, for spine surgery only) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the allograft rendered on December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Januvia.
You asked the Plan to pre-approve Januvia. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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-approve Januvia.
Benefits for Januvia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights