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

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient admission is medically necessary. The Plan denied your request. The Plan says an inpatient hospital admission is not medically necessary
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is undergoing a planned shoulder surgery. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. The reviewer found that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Therefore, the reviewer found that the requested inpatient hospital care 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 acute inpatient hospital care have not been met. Specifically, the file does not show that the enrollee is expected to require a greater than 2 midnight stay. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic visits to be provided by an OON
provider.
You asked the Plan to pre-approve the chiropractic visits. You say that you would like to continue to be treated
by this 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. The records provided for review do not show that the services at
issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the chiropractic
visits to be provided by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 19, 2020.

You asked the Plan to waive the copayment for laboratory services. You say that your benefits say that you owe a $0 copayment for laboratory services. 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 $0 copayment for laboratory services provided at a physician's office or independent lab location and a $25 copayment for laboratory services provided at all other locations.

The record shows that you received laboratory services at an outpatient hospital facility on August 19, 2020. Therefore, you are responsible to pay the $25 copayment. 

You have been asked to pay a $25 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular
partial denture (D5212).
You asked the Plan to pay for the complete maxillary denture and mandibular partial denture. You say that the
top denture you received never fit. You also say that you have not been able to sustain a proper diet and would
like these dentures approved so as to improve your nutritional status. The Plan denied your request. The Plan
says these services are allowed one time every 60 months. The Plan also says that you received these services
less than 60 months ago.
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, dentures are limited to one set every 5
years. The record shows that you received dentures on September 11, 2018, and your dentures benefit has been
exhausted. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110)
and a mandibular partial denture (D5212).
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 inpatient rehabilitation and more time to recover fully. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the dental service. You say that your partials have caused you discomfort since you got them in 2019. You say that your partials slip out of your mouth while you eat. You say that your dentist is not able to do additional adjustments to remedy the issue. You also say that you are on a very fixed income. The Plan denied your request. The Plan says 1 partial lower denture is covered every 5 plan years. The Plan also says that the frequency limit has been exceeded.
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 the dental service when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file shows that the Plan paid for a partial lower denture that you received on October 2, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 4, 2021.
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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this 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 the Intracept procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental/investigational procedure. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service and inpatient hospital care provided on June 14, 2021, through June 16, 2021.
You asked the Plan to waive the copayment for the ambulance service and inpatient hospital care. You say that you should not be responsible for the cost share. The Plan denied your request. The Plan says the cost share was applied 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 $300 copayment of each one way Medicare covered trip for ambulance service and a $325 copayment each day for inpatient hospital services. You have been asked to pay a $300 copayment of each one way Medicare covered trip for the ambulance service and a $325 copayment each day for the inpatient hospital care. 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 ambulance service and inpatient hospital care provided on June 14, 2021, through June 16, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Urinary Tract Infection testing provided on May 3, 2021.
You asked the Plan to pay for the Urinary Tract Infection testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this screening is not appropriate for the diagnosis code billed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare coverage criteria for this testing have been met. Specifically, this testing was ordered for a diagnosis of Urinary Tract Infection. This diagnosis indicates that this testing was not for screening purposes. It is the burden of the Health Plan to substantiate their denial with evidence. The documentation does not include evidence indicating that this testing was solely for screening purposes. This denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the Urinary Tract Infection testing provided on May 3, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like to see this specific doctor because you have had issues with the in-network doctor. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 specialist services to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom seat cushion (E2609) for a wheelchair.
You asked the Plan to pre-approve a custom seat cushion. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a custom seat cushion is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a custom seat cushion (E2609) for a wheelchair
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 more time in the current setting
due to their COVID diagnosis, and it is unsafe to transfer them at this time. The Plan denied your request. The
Plan says the enrollee has made progress in the current setting and is now at a point where their ongoing needs
can be met in a lower level of care.
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. 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 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 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 facet joint injections.

You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not
medically necessary.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications
established in the applicable LCD.

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 injections. Our reviewer says that
the requested facet joint injections are not medically reasonable and necessary in this case. Our physician
reviewer found that the enrollee is a 52-year-old female with a history of low back pain due to lumbar
spondylosis. She has pain with lumbar facet maneuvers bilaterally. She has tried and failed a recent home
exercise program, anti-inflammatories, and other medications. Although some information was supplied by the
provider, it was not sufficient to show the need for the medial branch blocks (MBBs). Therefore, based on the
lack of information, the bilateral L2-L3, L3-L4 MBB is considered 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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary visit provided on April 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that it is the nursing facility's responsibility to obtain authorization which should cover the rendering physician's medical treatment. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on April 23, 2021 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated abutments (D6056 x2), and an implant/abutment supported removable mandibular denture for edentulous arch (D6111).
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant/abutment supported removable mandibular denture. You say that you would like the implants to be covered. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 two surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated abutments (D6056 x2), and an implant/abutment supported removable mandibular denture for edentulous arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve the endosteal implant, prefabricated abutment, and abutment supported porcelain/ceramic crown. You say that these services are necessary, and you have a letter from your dentist supporting the implant. You also say that these services are important for you to function normally with your teeth. The Plan denied your request. The Plan says these services are not covered under your 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 a
surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain/ceramic crown (D6058).