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

We decided that the Plan does not have to pre-approve inpatient psychiatric services from September 10, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric services. You say that additional inpatient psychiatric care is needed as placement days. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric services. Our reviewer says that the continued inpatient psychiatric services are not medically necessary. Our physician reviewer found that this enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment from September 10, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services from September 10, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on April 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on April 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on June 3, 2021.
You asked the Plan to pay for a refraction. You say that this should be covered. The Plan denied your request.
The Plan says this was not provided by a routine vision care provider.
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 these services when provided by a network routine vision care provider.
We looked at the file and the Plan's rules. The service at issue was not provided by a network routine vision
provider. Based on this information, we decided that the Plan's rules for coverage of a refraction have not been
met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on June 3,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical implant placement (D6010), extraction (D7210) and unspecified preventive procedure (D1999) provided on October 19, 2020 and the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on February 2, 2021.
You asked the Plan to pay for the surgical implant placement (D6010), extraction (D7210) and unspecified preventive procedure (D1999), custom fabricated abutment (D6057) and abutment supported crown (D6058). You say that the tooth fractured below the gum necessitating restoration. You say that you should have been reimbursed. The Plan denied your request. The Plan says the maximum amount was reimbursed for the 2020 calendar year and the services provided on February 2, 2021 are not listed as covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you also had a maximum benefit of $500 for covered dental services in 2020. The Plan paid $500 toward the dental services received on June 25, 2020, July 31, 2020 and October 19, 2020, which exhausted your benefit. The custom fabricated abutment (D6057) and abutment supported crown (D6058) are not listed as covered benefits. Therefore, we decided that the Plan does not have to pay for the surgical implant placement (D6010), extraction (D7210) and unspecified preventive procedure (D1999) provided on October 19, 2020 and the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on February 2, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 17, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. 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 out of network physician services provided to the enrollee on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on April 26,
2021.
You asked the Plan to waive the copayment for the dermatology visit. You say that you were told there would
be no copayment since you did not see the actual doctor. 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 $25
copayment for specialist visits.
You have been asked to pay a $25 copayment for the dermatology visit. This copayment applies to any visit to
a specialist's office, even if you do not physically see a doctor. 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 dermatology visit you had on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88361, 88312, 88305, 88104) provided on November 17, 220.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services have been paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that additional units of CPT codes 88361, 88312, 88305, and 88104 are not supported in the medical record. Specifically, the records show that 4 units of code 88361, 1 unit of code 88312, 1 unit of code 88305, and 1 unit of code 88104, were provided on the date of service in question. The Plan has already processed an paid for these services. The additional units are not supported. 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 services (88361, 88312, 88305, 88104) provided on November 17, 220.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 25,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the services were not authorized because codes 84270 and 82306 are not a Medicare benefit for the
diagnoses listed on the claim and are done for screening purposes. The review indicates that the services at
issue in this case were 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services provided to the enrollee on February 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the patient reports being
limited with activities of daily living and walking. You say that the patient would benefit from physical therapy
to assess for a treatment program. The Plan denied your request. The Plan says additional visits are not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy
for this condition and can transition to an independent home exercise program. Our reviewer says that the
unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin Lispro (J1815) provided on March 18, 2021.
You asked the Plan to pay for the insulin. You say that you went to the emergency room and were given a drug for your diabetes. You also say that they were not aware that your insurance would not cover this because it was an emergency, and you would like the Plan to cover this. The Plan denied your request. The Plan says insulin is a self-administered drug and is not Part B covered.
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 pay for the insulin Lispro (J1815) provided on March 18, 2021.
Benefits for the insulin 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. The Plan denied your request. The
Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and
has been instructed in a home exercise program. Our reviewer says that the enrollee performs her exercises
with correct form and no pain. She also is noted to swim laps outdoors and can continue to improve her
conditioning with a home exercise program. Our reviewer says that the unique skills of a professional therapist
are not required to safely and effectively provide ongoing 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 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0554) and supply allowance (K0553), provided on March 18, 2021.
You asked the Plan to pay for a CGM and supply allowance. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is receiving devices they did not order.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a CGM and supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0554) and supply allowance (K0553), provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation (A0427,
A0425) and emergency care provided on May 1, 2021, to May 3, 2021.
You asked the Plan to waive the copayments for the emergency transportation and care. You say that these
services were necessary and related to a condition caused by COVID-19, so the Plan should waive the cost
sharing. The Plan denied your request. The Plan says the cost sharing for these services have been applied
correctly. Documentation shows that this care was not to treat COVID-19. In addition, copayment waivers for
COVID-19 treatment ended on March 31, 2021.
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 services and a $90 copayment for emergency care.
You have been asked to pay a $250 copayment for the ambulance transportation and a $90 copayment for
emergency care. Documentation shows that these services were not provided to directly treat COVID-19. 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 the ambulance transportation (A0427, A0425) and
emergency care provided on May 1, 2021, to May 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services.
You asked the Plan to pay for out of network services. You say that the Plan should cover these services. The Plan denied your request. The Plan says you did not have prior authorization for out of network care and you have denied authorization previously for this provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. 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 out of network physician services provided from December 3, 2020, to March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on April 22, 2021, and the periapical x-ray (D0220) provided on May 10, 2021.

You asked the Plan to pay for the dental services. You say that your tooth broke off in February 2020. You say that your dentist was unable to do anything outside of gluing the tooth back on because of the coronavirus lockdowns. You say that due to the extended delay, the interior of your tooth had degraded significantly. You also say that this x-ray is listed as a covered service. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that 1 periapical x-ray is covered per calendar year. 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up is not among those covered under this benefit. Although periapical x-ray is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on April 22, 2021. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on April 22, 2021, and the periapical x-ray (D0220) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a presbyopia correcting function of an intraocular lens
(V2788) provided on March 8, 2021, to April 19, 2021.
You asked the Plan to pay for presbyopia correcting function. You say that you are requesting reconsideration
to the reimbursement related to your intraocular lens procedures you had in March and April of this year. The
Plan denied your request. The Plan says this service is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a
conventional IOL.
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for a presbyopia correcting
function of an intraocular lens (V2788) provided on March 8, 2021, to April 19, 2021.