Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on January 2, 2021.
You asked the Plan to pay for air ambulance services. You say that air ambulance services were medically necessary. The Plan denied your request. The Plan says air ambulance services were not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that air ambulance services are not medically necessary. Our physician reviewer found that the enrollee is an 84-year-old who was diagnosed with pneumonia, pleural effusions who was transported via air ambulance to a different hospital. The enrollee was hemodynamically stable on transport. The documentation does support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation does not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The enrollee was hemodynamically stable and ground transport would have been a shorter distance, according to the records. The documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on January 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) from April 4, 2020, to April 10, 2020.
You asked the Plan to pay for the evaluation and management services. You say that the service provided were not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 4, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) from April 4, 2020, to April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an Octicon earmold provided on May 27, 2021.
You asked the Plan to reimburse you for an earmold. You say that you do not agree with the denial. The Plan denied your request. The Plan says this is an ineligible expense for Pick Your Perks reimbursement.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that you receive up to $550 of reimbursement with the Pick Your Perks program per calendar year for your out-of-pocket costs of purchasing Medicare approved supplemental benefits. The Plan contract also says that hearing aids and supplies are not eligible for reimbursement of the Pick Your Perks program. We looked at this physician's review, the file, and the Plan's rules. The service at issue is not covered under your contract with the Plan. Based on this information, we decided that the Plan's rules for coverage of an earmold have not been met. Therefore, we decided that the Plan does not have to reimburse you for an Octicon earmold provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested services are 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 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.
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. There is not a reasonable expectation that the 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 IRF admission and services.
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 a skilled nursing facility (SNF) admission can be approved.
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 pacemaker insertion. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341), gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381) provided on March 11, 2021.
You asked the Plan to pay for the periodontal scaling and root planing (D4341), gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381). You say that your dentist told you it was covered by insurance and you do not want to pay the bill. The Plan denied your request. The Plan says the services are not 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, 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 periodontal scaling and root planing (D4341), gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381) provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-ray and prophylaxis provided on April 12, 2021.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-ray and prophylaxis. You say that dental coverage for in-network and out-of-network is shown to have a $0 copayment. You say that you only found out about the difference after having the work done and you believe you are entitled to full coverage. The Plan denied your request. The Plan says the claim processed correctly per your out-of-network 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, the Plan is only obligated to pay the allowed amount for the periodic oral evaluation, bitewing x-ray and prophylaxis. You are responsible for any amount above what the Plan pays for covered dental services from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-ray and prophylaxis provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you do not want to go to the in-network doctor. The Plan denied your request. The Plan says there are in-network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.
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 rehab to get back to your baseline. The Plan denied your request. The Plan says you do not need an intensive team for 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 physician reviewer found that you were admitted to the acute care hospital for peritonitis and respiratory failure. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on August 19, 2020.
You asked the Plan to pay for physical therapy. You say that the patient was within an active plan of care reviewed and approved by an in-network prescribing provider. You say that the patient is entitled to Medicare approved services and the services should be approved for payment. The Plan denied your request. The Plan says prior authorization for out-of-network services was not 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 physical therapy provided by an out-of-network provider on August 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the doctors, nurses and aides feel that you should go to the SNF for two weeks. The Plan denied your request. The Plan says the stay is 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet the Medicare coverage criteria for admission to an SNF. Admission to an SNF is not reasonable and not medically necessary as you have no skilled nursing needs and do not need skilled therapies on a daily basis in an inpatient setting with the above functional status. You are medically stable after syncopal episode and continues with orthostatic hypotension on medication and needed no daily skilled nursing care. Documentation does not support the need for an admission to an SNF. Your rehabilitation needs can be met at a lower intensity level such as in home with services or in a long-term care (LTC) facility with intermittent therapies as needed. 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames and vision services (V2100, V2750, V2100, V2750, V2020) provided on January 6, 2021.
You asked the Plan to pay for eyeglass frames and vision services. You say that you visited this provider because it was cheaper. The Plan denied your request. The Plan says vision services will only be covered when they are received from a provider in the specified vision network.
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 contract says that supplemental routine vision services must be received from a participating provider in order to be covered by the plan. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. This service is not covered by the Plan when provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and vision services have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames and vision services (V2100, V2750, V2100, V2750, V2020) provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids (V5257) provided on February 17, 2021.
You asked the Plan to reimburse you for hearing aids. You say that you don't know why the provider sent the Plan a check for $500 when it should have been reimbursed to you. The Plan denied your request. The Plan says the Plan overpaid the provider; therefore, a refund was requested.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that you have a $500 combined in and out of network maximum benefit coverage amount for each hearing aid(s) (all types) up to 1 per ear, every 2 years. We looked at the file, and the Plan's rules. The records show that when the claim first processed, the Plan overpaid the provider, which was more than your maximum benefit coverage. A refund was requested by the Plan and you are responsible for the remaining balance. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5257) provided on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve Procrit. You say that this is medically necessary. The Plan denied your
request. The Plan says that there is no indication Retacrit would likely be less effective, and/or cause adverse
effects for the member.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Procrit. Our reviewer says that Procrit
is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Retacrit. There is
no documentation provided indicating that Retacrit would likely be less effective and/or likely have adverse
effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy
criteria for Procrit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313).
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable controller and harness) are not medically needed. They are needed when there is a medical need to control three power options through the joystick. Only one power feature (power tilt) has been approved. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377) and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 28, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 28, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 care from September 28, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 28, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 28, 2021, as he was not a danger to herself 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. 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 care from September 28, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 28, 2021, forward.