Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pre-approve the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330). We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).   You asked the Plan to pre-approve the comprehensive oral evaluation (D0150), panoramic x-ray (D0330) and the complete upper and lower denture (D5110 and D5120). You say that the lower denture distorted your face so you returned it. You say that the dentist advised you needed an upper and lower denture. The Plan says that your benefits are exhausted.  We decided that the Plan has to pre-approve the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330).   The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that you already received a comprehensive oral evaluation and panoramic x-ray. There was no documentation submitted showing the Plan already paid for a comprehensive oral evaluation or panoramic x-ray within your benefit period. There was also no documentation submitted showing that you have already exhausted your annual maximum benefit of $1,000. Therefore, we decided that the Plan has to pre-approve the comprehensive oral evaluation and panoramic x-ray.   We also decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).  Your contract with the Plan says that only one complete or partial denture is covered every 5 years. The Plan paid for the complete lower denture provided on June 10, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture.  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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization.

You asked the Plan to pre-approve the inpatient psychiatric hospitalization. The Plan denied your request. The Plan says this request is not medically necessary because the records received show that your condition has improved, and you are no longer a threat to yourself or others.

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 the inpatient psychiatric hospitalization. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 19, 2022 forward. Our physician reviewer found you did not require inpatient mental health treatment beyond the dates in question as you were not a danger to yourself or others and did not have any delusions but has baseline auditory no visual hallucinations. It does not appear that active treatment was taking place beyond the date in question. Our reviewer found that it does not appear that the services are reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Our physician reviewer also found that you could be treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation. You have baseline auditory no visual hallucinations, delusions and were 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 the inpatient psychiatric hospitalization have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device for the enrollee.  You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show the covered conditions.  The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.   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 HFCWOD. Our reviewer says that the requested vest is not medically reasonable or necessary.  Our physician reviewer found the enrollee does not have a Medicare covered diagnosis, such as cystic fibrosis, bronchiectasis, or neuromuscular disease. The record does not document use of other airway clearance treatments, such as manual percussion or flutter valve. There is insufficient evidence that this vest is beneficial in treatment of chronic obstructive pulmonary disease.  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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device for the enrollee.
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 there is a continuity of care issue for your services. The Plan denied your request. The Plan says you can receive care at an in-network 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 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee scooter.  You asked the Plan to pre-approve a knee scooter. You say that the scooter was recommended for ease of mobility and safety. The Plan denied your request. The Plan says this item is not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. The requested knee scooter is not covered by Medicare or your Plan due to not being medically necessary. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve the inpatient psychiatric services. The Plan denied your request. The Plan says the inpatient psychiatric care you are requesting do not meet the requirements for approval beginning January 20, 2022.

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 the inpatient psychiatric services. Our reviewer says that inpatient psychiatric services are not medically reasonable and necessary for you. Our physician reviewer found it was not expected you would improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you do not have dangerousness to yourself or others but were compliant with your treatment with encouragement. The Plan's denial of continued inpatient psychiatric services is appropriate.

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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial lower denture adjustment (D5422), and partial upper denture adjustment (D5410) provided on September 8, 2021.

You asked the Plan to pay for the denture adjustments. You say that you received dentures prior to your dental coverage ending. You say that it is your understanding that adjustments are covered within a year of the necessary, provided treatment plan. You say that the provider's office advised they no longer accept your dental plan. You also say that these services should be covered since you were covered at the time you received the dentures. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services obtained out of network are not covered.

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, dental services obtained out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial lower denture adjustment (D5422), and partial upper denture adjustment (D5410) provided on September 8, 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 are receiving adequate intensive rehabilitation in the inpatient rehabilitation facility.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 do not have documented skilled nursing or therapy needs. You remain non-ambulatory and in need of assistance for activities of daily living. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are considered custodial and intermittent.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Sarclisa.  You asked the Plan to pre-approve Sarclisa. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Sarclisa. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Sarclisa is medically reasonable and necessary for the enrollee. The documentation does not support that the Sarclisa is safe and effective for 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 Sarclisa have not been met. Therefore, we decided that the Plan does not have to pre-approve Sarclisa.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the ForeseeHome monitoring program for the enrollee.  You asked the Plan to pre-approve the program. You say that this is medically necessary. The Plan denied your request. The Plan says this is not the standard of care to monitor macular degeneration progression.  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 program. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found overall, the records available do not support that the ForeseeHome monitoring program is the standard of care in monitoring the enrollee's age related macular degeneration.  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 program have not been met. Therefore, we decided that the Plan does not have to pre-approve the ForeseeHome monitoring program for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits with a specialist (99203, 99213) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office visits with a specialist. You say that you need to start your radiation therapy as soon as possible. You requested a provider closer to your home as you are 82 years old, and you have an eyesight problem. You also say that you will be having a weekly appointment which is why it is safer to go to a closer facility. You are willing to go to another facility if this facility is not approved. The Plan denied your request. The Plan says services provided by an OON provider are not covered with your Plan. The Plan also says that they have approved services with an in-network 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 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 office visits with a specialist (99203, 99213) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. 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 dermatology 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 waive the deductible and copayment for an inpatient hospital stay provided by a participating provider on May 6, 2021, to May 10, 2021.

You asked the Plan to waive the deductible and copayment for an inpatient hospital stay. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct deductible amount has been 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 $1,000 deductible for inpatient hospital stay. 

You have been asked to the correct amount for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital stay 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 deductible and copayment for an inpatient hospital stay provided by a participating provider on May 6, 2021, to May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for K3 prosthesis does not meet Medicare criteria as reasonable and 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee is a K3 ambulator or is expected to be a K3 ambulator with the new prosthesis. The records report that the enrollee is expected to use a cane with the new prosthesis; this is not consistent with a K3 functional level.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee/foot feature for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there have been no specific studies done to identify that the basivertebral nerve is the cause of the pain.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy.  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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic exercises (97110) to be rendered by an out-of-network (OON) provider.  You asked the Plan to pre-approve the therapeutic exercises. You say that the enrollee is in New Hampshire in an assisted living facility due to a second stroke. You also say that the enrollee needs physical therapy immediately because it is medically necessary. The Plan denied your request. The Plan says there are available physical therapy providers in the enrollee's Primary Care Physician's (PCP) referral circle that can meet the enrollee's needs. The Plan also says that there is no evidence that the enrollee is unable to see a provider within the referral circle or that seeing a provider within the referral circle would not meet the enrollee's needs.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.       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 therapeutic exercises. Our reviewer says that this request is not medically reasonable and necessary. Our physician reviewer found the enrollee could not have foreseen requiring the services prior to leaving his service area. Our reviewer found that the records indicate that the care requested is medically necessary. However, it was not clearly shown in the notes that the enrollee would not be able use an in-network physical therapist, as they are only 8 miles away from Massachusetts. Our physician reviewer also found that it would not be medically reasonable to delay the services, but transport to physical therapy and back would not be extensive considering how close they are to in-network physical therapists.  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 therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic exercises (97110) to be rendered by an out-of-network (OON) provider.