Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from March 11, 2020, to March
14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the DRG is not
supported.
The Plan must follow Medicare rules. Medicare rules say that the 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. The documentation submitted does not contain medical records from
the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been
met. Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for the inpatient care provided from March 11, 2020,
to March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Verio One Test Strips.
You asked the Plan to pre-approve Verio One Test Strips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a plan preferred brand.
Medicare rules say that plans can require enrollees to get supplies from preferred providers. The contract with the Plan says that the Plan has to pre-approve diabetic supplies from plan preferred brands. Review of the file shows that you are requesting diabetic supplies to be provided by a non-preferred brand. The documentation does not support rationale or a reason why the preferred test strip brand cannot be used.
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 Verio One Test Strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three core buildups, including any pins when required (D2950 x3).
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 pre-approve three core buildups, including any pins when required (D2950 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the four gingival irrigations (D4921 x4).

You asked the Plan to pre-approve the gingival irrigations. You say that you need a deep cleaning because you have not had one in a long time. The Plan denied your request. The Plan says this service is not covered under your benefit plan.

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 pre-approve the four gingival irrigations (D4921 x4).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an implanted spinal pain medication
pump.

You asked the Plan to pre-approve the implanted pain pump. You say that you feel that this should be covered
due to your extreme pain which has not been helped by other treatments. The Plan denied your request. The
Plan says until a temporary trial shows acceptable pain relief, this cannot be covered.

The Plan follows Medicare rules. Medicare rules say that an implantable infusion pump is covered when used
to administer opioid drugs for severe chronic intractable pain, after a trial shows it is successful.
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 implanted pain pump. Our reviewer
says that the documentation does not support that the permanent implantation is medically necessary at this
time. Our physician reviewer found the record indicates that the enrollee has intractable pain syndrome and has
failed conservative measures. The record does not indicate that the enrollee has undergone a trial of a
temporary catheter. The elements of the coverage criteria are not satisfied.

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 implanted pain pump have not been met. Therefore, we decided that the
Plan does not have to pre-approve placement of an implanted spinal pain medication pump.
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 the enrollee is unsafe to go home. The Plan denied your request. The Plan says the enrollee does not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient.
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 physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, his lungs were clear, and he was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at a contact guard to minimal assist level with functional mobility. He 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. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that the requested procedure is medically
reasonable and necessary. The Plan denied your request. The Plan says this procedure is considered
experimental/investigational.

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 Vertiflex procedure. 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 20, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that your benefits state that you do not owe anything for ambulance services if you do not receive transportation. 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 $250 copayment for ambulance stabilization when there is no transport. 

You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had at an orthopedic surgeon's
office on April 30, 2021.

You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that you didn't see the
doctor on this date- you only saw the nurse practitioner. Because of this, you do not feel as though you should
pay a copayment. 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 $15
copayment for visits with a specialist.

You have been asked to pay a $15 copayment for the orthopedic surgery visit. The medical records from this
date of service show that you did have an office visit with the nurse practitioner in the orthopedic surgeon's
office. According to your Evidence of Coverage, the specialist copayment applies to both physician and
practitioner services received in a specialist's office. 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 visit you had at an orthopedic surgeon's office on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Foresee Home eye monitoring device.
You asked the Plan to pre-approve a Foresee Home eye monitoring device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
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 a Foresee Home eye monitoring device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has non-exudative age-related macular degeneration. The record submitted does not contain medical records supportive of the requested service. The provided records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's specific clinical condition. Therefore, the enrollee does not meet criteria for the requested device. 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 Foresee Home eye monitoring device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Foresee Home eye monitoring device.
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 you need intensive physical therapy. The Plan denied your request. The Plan says you do not require an intensive multidisciplinary approach to daily 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 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 physician reviewer found that you were admitted to the acute care hospital leg weakness and trouble walking. You were discharged home. Your medical problems are stable. You do not require treatment by multiple therapies in 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says there are not enough studies to show the procedure is safe and effective to treat back pain.
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 requested services. Our physician reviewer found that the enrollee has chronic axial ow back pain with occasional radicular pain down the left leg. Her magnetic resonance imaging (MRI) shows multi-level disc extrusion and neuroforaminal stenosis. An epidural steroid injection did not provide significant relief. The request is for an Intracept procedure, which includes multiple radiofrequency ablations of the basivertebral nerves. This enrollee has several clear pain generators that have not been surgically addressed. The requested procedure is considered experimental/ investigational. Therefore, the request is deemed not medically reasonable 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81406, 81407, 81408)
provided on May 13, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this was medically necessary.
The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular
screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary
cardiovascular screening (81406, 81407, 81408) provided on May 13, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you did not appear to require inpatient mental health treatment beyond the date in question as you are not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations while being cooperative with treatment. It does not appear that active treatment is taking place beyond the date in question. 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: Favorable

We decided that the Plan has to pre-approve medial branch blocks.
You asked the Plan to pre-approve the requested services. You say that the enrollee was more functional after the first procedure. The Plan denied your request. The Plan says that three levels of treatment are not required.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has chronic low back. He has tried physical therapy, chiropractic services and transcutaneous electrical nerve stimulation. He continues with a home exercise program. He underwent a first set of diagnostic medial branch blocks (MBBs) at 2 levels (3 nerves blocked) and achieved 80% pain relief. The request is to repeat the MBBs as required before radiofrequency ablation. The request is to block 2 levels (3 nerves) and not 3. The request for 2 levels of a 2nd set of diagnostic MBBs 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve medial branch blocks.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient hospital facility on May 13. 2021.
You asked the Plan to waive the copayment for the lab services. You say that this should be paid in full because it was for a diabetes follow-up. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the provider can submit the balance of this $15 owed to Medicaid. The Provider indicated they will do so once your Medicaid information is provided.
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 $15 copayment for lab services at an outpatient hospital facility.
You have been asked to pay a $15 copayment for the lab services. This copayment applies regardless of the reason for the lab services. 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 lab services you received at an outpatient hospital facility on May 13. 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural.

You asked the Plan to pre-approve epidural. You say that the enrollee is scheduled for a repeat procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan approved one unit, but a second epidural is not covered because the response to each epidural should be determined prior to determining the value of a repeat injection.

The Plan follows Medicare rules. Medicare rules state that epidural injections may be covered under certain circumstances.

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 epidural. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested epidural. Our physician reviewer found per documentation from September 22, 2021 a cervical epidural steroid injection was done. The enrollee had greater than 50% benefit from the injection and quality of daily functioning has improved. The treating provider has recommended another epidural steroid injection for November 3, 2021. According to the coverage criteria, a repeat epidural steroid injection is indicated if there has been at least 50% improvement of pain for a duration of at least 3 months, which has not yet passed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic surgery services.
You asked the Plan to pre-approve the requested services. You say that surgery will help with your pain. The Plan denied your request. The Plan says you must get approval from your primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that your primary care physician coordinates your covered services you get as a plan member. We looked at the file and the Plan's rules. The file does not indicate a referral was requested or provided for the necessary services. Based on this information, we find that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve orthopedic surgery services.