Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says ventilator settings that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a ventilator. Our physician reviewer found that the enrollee has severe COPD and ischemic cardiomyopathy, with a recent hospitalization for exacerbation of congestive heart failure. The record does not include an arterial blood gases test, done while stable, showing carbon dioxide (CO2) retention. Even if the enrollee has CO2 retention, Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP devices can provide the required mode of support. Therefore, a home ventilator is not medically 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system.

You asked the Plan to pre-approve Intracept intraosseous nerve ablation system. 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. 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 Intracept intraosseous nerve ablation system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has longstanding back pain. The Intracept procedure is experimental. More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept intraosseous nerve ablation system have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not require LTACH services that are not already available at the current facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hyperbaric oxygen treatment.  You asked the Plan to pre-approve hyperbaric oxygen treatment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.  The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered for certain indications.  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 hyperbaric oxygen treatment. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have a traumatic brain injury. This is not listed as a covered indication for hyperbaric oxygen treatment. This means you do not have a diagnosis/condition that meets criteria for the requested services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve subcutaneous cardiac rhythm monitor, including programming.  You asked the Plan to pre-approve subcutaneous cardiac rhythm monitor. 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 follows Medicare rules. Medicare rules say that subcutaneous cardiac rhythm monitor is only covered for certain indications.  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 subcutaneous cardiac rhythm monitor. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a past medical history of paroxysmal atrial fibrillation. Based on the medical records provided there is no documentation that the enrollee has a diagnosis/condition that meets criteria for the requested subcutaneous cardiac rhythm monitor, including programming. Records do not document (as required by the National Coverage Determination (NCD): Electrocardiographic Services - 20.15) that the enrollee has had syncope "thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom MLR."       We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve subcutaneous cardiac rhythm monitor, including programming.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a crown (D2752) provided by a participating provider on August 9, 2021.  You asked the Plan to pay for a crown. You say that you cannot afford this amount. You say that because of Covid-19 you are not working as much. The Plan denied your request. The Plan says you pay 100% of charges beyond the $2,750 allowance or if you exceed a service limit.  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 up to a $2,750 allowance. You are responsible for 100% of charges after $2,750.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown (D2752) provided by a participating provider on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not require LTACH services that are not already available at the current facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 18, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from January 18, 2022, 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 January 18, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 18, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond January 18, 2022, 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.  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 January 18, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 18, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided August 2, 2021.  You asked the Plan to pay for a pneumatic compression device and appliance. You say that this was a necessary and normal equipment for surgery and should not be denied. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided August 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have skilled nursing or therapy needs to be provided on a daily basis as an inpatient.  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 services. Our physician reviewer found that you presented to the acute hospital with chest pain and shortness of breath. You were found to have evidence of a myocardial infarction and underwent a cardiac catherization showing significant coronary artery disease. You underwent a coronary artery bypass graft procedure, and your condition has since stabilized. You are walking 40 to 50 feet with a rolling walker with minimal contact guard assistance and are at a moderate assist level for transfers and some activities of daily living. There are no documented skilled nursing service needs. Although there are skilled therapy service needs, you do not require services on a daily basis in a SNF setting.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of x-rays (D0210), alveoloplasty (D7310), complicated sutures (D7911), gingival irrigation (D4921) and tissue conditioning (D5851, D5850) provided on April 22, 2021.

You asked the Plan to pay for the dental services. You say that you expected these services to be covered in full, and feel the Plan was misrepresented to you by the agent you spoke with. The Plan denied your request. The Plan says these services are not covered by your dental benefit. In addition, outside insurance brokers are independent contractors and not employed directly by the 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 pay for the complete series of x-rays (D0210), alveoloplasty (D7310), complicated sutures (D7911), gingival irrigation (D4921) and tissue conditioning (D5851, D5850) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 4, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you feel that you should not have another copayment because the technician was out of the office on your first visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each office visit with a specialist.   You have been asked to pay a $40 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device.  You asked the Plan to pre-approve the Vertiflex device. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental.  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 Vertiflex device. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is 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 the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
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 there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy.
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the
rehabilitation needs can be safely met in an alternate and lower intensity setting.

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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the admission is medically necessary. The Plan denied your request. The Plan says the requested admission is not medically necessary as you do not need to be seen by a rehab doctor more than 3 times per week for evaluation. The Plan also says the provided documentation does not show that you require 3 hours of therapy a day to get better.  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 documentation does not support that you would meet criteria for admission to an acute inpatient rehabilitation facility. The reviewer found that there is no indication that you would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. Therefore, the reviewer found that the requested IRF 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 IRF care have not been met. Specifically, the file does not indicate that you require 15 hours of rehabilitation services per week. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided from January 19, 2021, to May 10, 2021.  You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never received a bill for the supplies previously. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 20% coinsurance for durable medical equipment (DME) supplies.     Item Allowed Amount 20% Coinsurance Ostomy Pouch (A4389) $144.60 $28.92 Skin Barrier, Wipes or Swabs (A5120) $7.00 $1.40 Adhesive Remover, Wipes (A4456) $14.00 $2.80 Total:  $33.12  You have been asked to pay $33.12, which is 20% of the allowed amount for the ostomy supplies. Ostomy supplies fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for ostomy supplies provided from January 19, 2021, to May 10, 2021.