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

 We decided that the Plan does not have to pre-approve a partial hospitalization program (PHP) admission.  
You asked the Plan to pre-approve a PHP admission. You say that you do not want hospitalization. You say that in your crisis you are stable. You say that you need help. You also say that you would like to start as soon as possible. The Plan denied your request. The Plan says the enrollee can benefit from treatment by mental health professionals at a less restrictive outpatient level of care.  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 a PHP admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not showing any dangerousness to self or others, is tolerating treatment, and not showing any perceptual disturbance or psychosis. The reviewer found that you are noted to be much improved, able to exercise, and your thinking was improved. The reviewer found that you were cooperative with care, and actively involved in your treatment. Therefore, the reviewer found that the requested partial hospitalization program admission 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 a PHP admission have not been met. Specifically, the file shows that you are not of danger to yourself or others. Therefore, we decided that the Plan does not have to pre-approve a partial hospitalization program (PHP) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.  
You asked the Plan to pre-approve an intracept procedure. You say that your back pain interferes with our daily life activities. You say that you are having difficulty getting out of bed in the morning and assuming regular activities, such as dressing and showering. You say that you used to be able to take walks every day, but now find it difficult. You say that your doctor has recommended the requested procedure for treatment of your vertebrogenic pain. The Plan denied your request. The Plan says the requested procedure is not considered to be useful for back pain at this time.  
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 an intracept procedure. Our reviewer says that an intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. He has tried physical therapy, NSAIDs, ice/heat and injections. His magnetic resonance imaging (MRI) shows Modic Type II changes at L3-L4 and L4-L5. The request is for radiofrequency ablation of the basivertebral nerves at L3, L4 and L5.   This is considered an experimental/ investigational procedure  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on July 7, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET-CT scan (78815).  
You asked the Plan to pre-approve a PET-CT scan. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. 
The Plan says medical necessity rules for the requested service have not been met.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET-CT scan. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that a PET-CT scan is not indicated for surveillance of lymphoma according to medical guidelines.         
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 PET-CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET-CT scan (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided July 22, 2021.  You asked the Plan to pay for the first and additional intraoral x-rays. You say that you were not aware the dentist was going to do 3 x-rays and the dentist should have known that only 1 was covered. The Plan denied your request. 
The Plan says you have exceeded the frequency limit for this service.  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 one dental x-ray per year.  We looked at the file and Medicare rules. In this case the Plan provided documentation that one set of x-rays was already covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for coverage of the first and additional intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided July 22, 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 enrollee needs daily physician oversight, 24/7 nursing care, nutrition services, and physical, occupational, and speech therapies. The Plan denied your request. The Plan says the records do not show that the enrollee has a severe complex infection. The Plan says that the enrollee does not have a complex wound. The Plan says that the enrollee is recovering from an acute illness. The Plan says that the services needed can safely be received in another setting.  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 enrollee was admitted with respiratory failure due to pneumonia in the setting of a cancerous neck mass. The record indicates that the enrollee has labile oxygen requirements and significant secretions. The record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (70450) provided on August 10, 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 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. 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 August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on February 22, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that he POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code.Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scratch resistant coating, per lens (V2760) provided on  June 28, 2021.  You asked the Plan to pay for scratch resistant coating, per lens. 
The Plan denied your request. The Plan says eyeglasses are a covered benefit; however, upgrades are not covered.  Additional lens options including, but not limited to, Deluxe, Premium or Platinum progressive lenses, blended bifocal, Hi Index, tinting, scratch coating, UV or anti-reflective coating, and polycarbonate are not covered.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   
We looked at the file and the Plan's rules. The file shows that the Plan's vision benefit does not cover scratch resistant coating. Therefore, we decided that the Plan does not have to pay for scratch resistant coating, per lens (V2760) provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) provided July 27, 2021.  You asked the Plan to pay for the unspecified preventive procedure. 
You say that you were not told this item was not covered. The Plan denied your request. The Plan says this service is not covered under your 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 unspecified preventive procedure, by report (D1999) provided July 27, 2021.   Your complaint about not being told directly by a Plan representative or the provider prior to the service that this service is not covered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 8, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. 
The Plan says eye refractions are not a covered benefit.  The Plan must follow Medicare rules. 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  We looked at the file and the Medicare rules. 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on June 15, 2021.  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 must 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 medical services provided to the enrollee on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an implantable defibrillator pulse generator; multiple lead system and Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable system (33264, 33225).  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member would need to have an ejection fraction of 35% or less in order to meet the coverage criteria.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The records indicate a history of hypertension treated with lisinopril at the time of the March 2021 echocardiogram. Afterward, he was started on a beta blocker. There is no documentation of a repeat echocardiogram after administration of optimal medical therapy for congestive heart failure (CHF), as guidelines suggest. Moreover, the degree of left ventricuar dysfunction is not severe at 44%, well above the 35% threshold cited by guidelines for cardiac resynchronization therapy (CRT) pacemaker (CRT-P) candidacy and likelihood of favorable response to bi-ventricular pacing. There is insufficient documentation to support the medical necessity for removal of the dual-chamber pacemaker and replacement with a bi-ventricular pacemaker. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable defibrillator pulse generator; multiple lead system and Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable system (33264, 33225).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services you received from an out-of-network provider on March 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the x-ray services you received from an out-of-network provider on March 10, 2021.
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 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation.  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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 10, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that the Plan's customer service agent gave you incorrect information regarding the network status of the hospital.  
As a result, you had to go to an urgent care center, where you said you received unprofessional care.  You then had to return to the ER to have your finger treated. 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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. This cost sharing applies regardless of the reason for the ER visit. 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 emergency room (ER) visit you had on July 10, 2021.   Your complaint about the information provided to you by customer service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for contact lenses provided on  August 2, 2021.  You asked the Plan to pay an additional amount for contact lenses. The Plan denied your request. The Plan says that on August 2, 2021, you received contact lenses that totaled $219.52, the remaining $145.00 of your allowance applied to the cost of the contact lenses leaving you with the remaining $74.52 as your cost share.  
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows the Plan paid the correct vision allowance. Therefore, we decided that the Plan does not have to pay an additional amount for contact lenses provided on  August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided May 10, 2021.  You asked the Plan to pay for the comprehensive oral exam. 
You say that you switched to a network provider and required a new comprehensive exam. The Plan denied your request. 
The Plan says you have exceeded the frequency limit for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. 
For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive oral exam once every three plan years.  We looked at the file and Medicare rules. 
The Plan provided documentation showing that a comprehensive exam was previously covered on November 13, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided May 10, 2021.