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

We decided that the Plan has to pay for hospital readmission provided from March 18, 2021 to March 23, 2021.
You asked the Plan to pay for hospital readmission. You say that the services were necessary, and payment
should be rendered. The Plan denied your request. The Plan says that based on the documentation provided,
coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that readmission 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 pay for hospital readmission. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the review has determined that the
readmission was medically necessary and did not result from a premature discharge from the same hospital.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hospital readmission have been met. Therefore, we decided that the Plan has to
pay for hospital readmission provided from March 18, 2021 to March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on May 7, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you specifically went to the doctor for an annual wellness exam, so there should be no copayment. The Plan denied your request. The Plan says it has waived the office visit copayment, but you are still responsible for the lab copayment. The Plan says that because the allowed amount for the lab services ($3.48) is less than your copayment obligation, you are responsible for the full allowed 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. Annual physicals do not include lab services, so separate cost sharing can apply for that. 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 lab services you received on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160) and
preventive procedure (D1999) provided on March 20, 2021.
You asked the Plan to pay for the detailed and extensive oral evaluation and preventive procedure. You say that
the dental office charged you $100.00 up front because they said your plan does not pay a lot. You also say that
there was not an extensive oral evaluation or preventive procedure. The Plan denied your request. The Plan
says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of
service to verify benefits and provider eligibility.
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
detailed and extensive oral evaluation (D0160) and preventive procedure (D1999) provided on March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the eye exam and refraction provided on May 12, 2021.
You asked the Plan to pay more toward the eye exam and refraction. You say that the provider would not be able to prescribe glasses without refracting your eyes. You say that you have not been covered for an eye exam since your diagnosis of macular degeneration and you expect the claim to be adjusted and paid. The Plan denied your request. The Plan says the copayment applied correctly to the eye exam and the refraction remains denied as a non-covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a medical eye exam with a $40 copayment and a refraction is only covered with a routine eye exam from the Plan's supplemental vision provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the eye exam and refraction have not been met. The records show the claim processed correctly as a medical eye exam was billed. Therefore, we decided that the Plan does not have to pay more toward the eye exam and refraction provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, intraoral periapical x-rays, and resin-based composite provided on June 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, intraoral periapical x-rays, and resin-based composite. You say that you changed dentists because your previous provider was out-of-network and you had to pay additional money every month for dental insurance. You also say that you contacted this treating provider to see if they would accept your insurance. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you.
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, you are responsible for the difference between the billed amount and allowed amount for covered services received OON. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, intraoral periapical x-rays, and resin-based composite provided on June 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve ten (10) additional one-way non-emergent ambulance transportation trips.
You asked the Plan to pre-approve thirty (30) additional one-way non-emergent ambulance transportation trips. You say that the enrollee requires 2 times a week visits to the clinic at the hospital for foot care and follow-up. You say the enrollee requires the maximum assistance and is bed confined and must be transferred per stretcher. The Plan denied your request. The Plan says that ten (10) one-way non-emergent ambulance transportation trips are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided us with the exact Plan rules to support if this transport based on a Plan supplemental, routine transportation benefit. Therefore, we decided that the Plan has to pre-approve ten (10) additional one-way non-emergent ambulance transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer from one skilled nursing facility to another.
You asked the Plan to pre-approve transfer from one facility to another. You say that this transfer is medically necessary for continued care. The Plan denied your request. The Plan says the enrollee is receiving the required care in the current facility and can be transitioned to the next phase of care from the current facility.
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. Medicare only allows transfer from one facility to another when the required care cannot be provided by the originating facility. There is no indication in the records that you require care at a different facility that cannot be provided at the current facility. The Plan is providing the required care and can transition you to the next level of care when appropriate. Therefore, we decided that the Plan does not have to pre-approve transfer from one skilled nursing facility to another.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve dialysis services. You say that these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says they have in-network providers available to provide the medical care the enrollee requires.
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 dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an implantable loop recorder.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that you did not have fainting episodes thought to be heart related.
The Plan must follow Medicare rules. Medicare rules say that electrocardiographic services are only covered under certain medical indication.
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 you have known paroxysmal atrial fibrillation (PAF) but have been very difficult to manage with medications due to many side effects. You have persistent dizzy spells and lightheadedness. There is evidence of conduction system disease on your baseline EKG and an episode of bradycardia and Mobitz 1 block on the prior external monitor. You would certainly have a high pre-test probability of having tachy/brady symptoms given your age, history of PAF, comorbidities and baseline EKG abnormalities. As you have also been difficult to diagnose and manage, a longer term monitor to assess for symptomatic or more profound bradycardia or atrioventricular (AV) block is clinically reasonable and appropriate, and would therefore meet the requirements for the use of more prolonged monitoring with an implantable loop recorder. This is especially true since the external monitoring devices have failed to define an etiology of her symptoms and a finding of more profound AV block would necessitate pacemaker implantation. 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 an implantable loop recorder.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rhinoplasty (CPT code 30420), osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) (CPT code 21208) and repair of brow ptosis (supraciliary, mid-forehead or coronal approach) (CPT code 67900).
You asked the Plan to pre-approve the services. You say that you are now requesting this procedure on your brow, described by your doctor as saying you feel your "eyebrows are heavy" and feel like your eyes may block your vision. You state you are requesting other cosmetic procedures to your jaw and nose. The Plan denied your request. The Plan says cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one's appearance, is not covered and your request is not a covered benefit because your records do not show documented visual problems, measured by objective measurement of your visual field.
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 services. Our physician reviewer found the record indicates that you are a male to female transsexual. The record indicates that you were last evaluated by the psychiatrist in October 2020. The record does not indicate that you are on hormonal therapy. The record does not indicate that you have had gender affirming surgery. The provided record does not establish the medical necessity of the requested procedure for your diagnosis of gender dysphoria. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The record supports that the requested procedure is being performed for cosmetic reasons. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve rhinoplasty (CPT code 30420), osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) (CPT code 21208) and repair of brow ptosis (supraciliary, mid-forehead or coronal approach) (CPT code 67900).
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 would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission 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 you have a past medical history of chronic pain syndrome, synovial cyst of the knee
and atherosclerotic coronary artery disease and are living in an assisted living facility with complaints of
weakness. Your 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 a
intensive, multi-disciplinary rehabilitation program. Therefore, your care needs can be met 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 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: 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 admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is status post fall with left ankle fracture. The enrollee received oral medications and insulin. The enrollee had stable vital signs. The enrollee required contact guard to modified independent level with functional mobility. The documentation does not support that the enrollee requires skilled nursing or skilled therapy services on a daily basis. The enrollee's care needs can be met 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 admission 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the breast ultrasound you had on June 4, 2021.
You asked the Plan to waive the deductible for the breast ultrasound. You say that you were not aware that an ultrasound for dense breasts would not be considered preventive. You said that this test must be used just like a mammogram if one has dense breasts. The Plan denied your request. The Plan says you had not met your deductible at the time you received this service and this is a service to which the deductible applies.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $395 deductible which applies to outpatient hospital services and radiology services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $395 deductible which applies to outpatient hospital services and radiology services. While we understand that breast ultrasound may be the standard of care for a patient with dense breast tissue, the fact remains that your contract with the Plan only covers mammograms and breast exams as copayment-free breast cancer screenings. Ultrasounds are not covered under this benefit. Ultrasounds are radiology services to which the deductible applies. This cost sharing is a contractual obligation that had not been met at the time the breast ultrasound was received on June 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the breast ultrasound you had on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the routine laboratory services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the routine laboratory services. You say that it is more convenient to get your laboratory work from the out-of-network provider. The Plan denied your request. The Plan says the provider is out-of-network.
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 routine laboratory services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight non-autogenous connective tissue grafts (D4275 x8).
You asked the Plan to pre-approve the non-autogenous connective tissue grafts. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 eight non-autogenous connective tissue grafts (D4275 x8).