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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 19, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you went to an urgent care facility and should owe $0. 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 $40 copayment for specialist services. The record shows that you received specialist services on June 19, 2021. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 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 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 a specialist visit provided on June 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3320).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a limit one procedure per year.
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 endodontic therapy (D3320) once per year. The case file shows that the same service was last received on September 2, 2021. This exceeds the plan limit for this service. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D3320).
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 do not want to stay in the hospital, and you are
doing everything you're asked to do. You say that additionally, if you go to skilled nursing home you will die.
The Plan denied your request. The Plan says the enrollee can safely receive the services he needs in other
settings, for example: a skilled nursing facility, home with home health services or home with outpatient
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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found 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, multidisciplinary
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: 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 the Plan's denial is delaying the 
enrollee's ventilator and rehabilitation needs. You say that LTACH care is medically necessary. You say that 
the enrollee needs speech therapy, physical therapy, and occupational therapy to improve cognitive abilities. 
You say that the enrollee needs diagnostic monitoring with oxygen saturations for improved success of 
ventilator weening. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 
not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet joint blocks.
You asked the Plan to pre-approve diagnostic facet joint blocks. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically necessary when specific criteria are met. 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 diagnostic facet joint blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found intra-articular facet joint blocks are covered only when there are anatonmic issues or the presence of a device that would be adversely affected by radiofrequency ablation (RFA). Coverage guidelines do not support intra-articular therapeutic blocks. This request is 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 diagnostic facet joint blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint blocks
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: at the skilled nursing 
facility, or home with health services. 
 
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 was admitted for rhabdomyolysis after a fall and has been transferred to skilled nursing facility. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a phrenic nerve stimulator system for treatment of
central sleep apnea.
You asked the Plan to pre-approve a phrenic nerve stimulator system. You say that the enrollee has attempted
and failed conventional treatment. The Plan denied your request. The Plan says the requested services are not a
covered benefit.
The Plan must follow Medicare rules. Medicare rules say that transvenous phrenic nerve stimulation for central
sleep apnea is noy covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a phrenic nerve stimulator system have not been met. Therefore, we decided that the Plan does not
have to pre-approve a phrenic nerve stimulator system for treatment of central sleep apnea.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Huntington disease gene analysis. 
 
You asked the Plan to pre-approve Huntington disease gene analysis. You say that the test was not conclusive 
and needs to be performed again. The Plan denied your request. The Plan says the enrollee tested positive for 
Huntington disease and the rules for repeat genetic testing 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 Huntington disease gene analysis. Our 
reviewer says that Huntington disease gene analysis services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support that repeat genetic 
testing for Huntington's disease is medically reasonable and necessary for the enrollee in this case. The testing 
has been done previously, and it has not been demonstrated that the results of repeat testing would directly 
impact the treatment and outcome of the enrollee. The documentation does not support that repeat testing 
would assist in modifying the enrollee's current treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Huntington disease gene analysis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Huntington disease gene analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extractions.
You asked the Plan to pre-approve surgical extractions. You say that the service at issue is necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 surgical extractions
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy visits provided from December 21, 2020, to January 4, 2021.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the required documentation was requested and not received. The Plan also says that the documentation provided does not support the services at issue in this case.
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. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the documentation provided does not support the services at issue in this case. Therefore, we decided that the Plan does not have to pay for the physical therapy visits provided from December 21, 2020, to January 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.

You asked the Plan to pre-approve medical nutrition therapy services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the molar surgery procedures (D3425, D3426) and retrograde fillings (D3430) provided on April 27, 2021.

You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

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 molar surgery procedures (D3425, D3426) and retrograde fillings (D3430) provided on April 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says the rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found Based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are functioning at/near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services provided on April 22, 2021, and April 26, 2021.

You asked the Plan to waive the copayments for specialist services. You say that these were follow-up visits and 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 $40 copayment for specialist services. 

You had follow-up visits on April 22, 2021, and April 26, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80.

You have been asked to pay the total copayment amount of $80 for specialist services. Specialist services fall 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 your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for specialist services provided on April 22, 2021, and April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ADmark Alzheimer's Evaluation testing.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific criteria are met. 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 stated mild cognitive impairment. She reported poor short-term memory. Neuropsychology evaluation from April 6, 2021 noted moderate to severe neurocognitive disorder, predominantly executive function but mild spatial reasoning, learning, and memory. Magnetic resonance imaging (MRI) of the brain on March 31, 2021 revealed a few nonspecific white matter changes but no notable atrophy. The documentation does not support that the results of the testing would directly impact the treatment or management of this enrollee. The documentation does not support that ADmark Alzheimer's Evaluation testing is medically reasonable and necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve ADmark Alzheimer's Evaluation testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod Mis 5 Pack for the enrollee.
You asked the Plan to pre-approve Omnipod Mis 5 Pack. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, such as the Omnipod, are not covered by Medicare Part B as they do not meet the definition of durable medical equipment. Although this may be appropriate for the enrollee, neither Medicare nor the Plan covers this device. Therefore, we decided that the Plan does not have to pre-approve Omnipod Mis 5 Pack for the enrollee.
Benefits for Omnipod Mis 5 Pack 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 Revlimid for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for 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 Revlimid for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.