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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need to be admitted to the IRF. The Plan denied
your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an
acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. While you have a need for
physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy
program. There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility services.
You asked the Plan to pre-approve the continued Skilled Nursing Facility services. You say that the skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says coverage criteria is no longer met.
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 the continued Skilled Nursing Facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 the continued Skilled Nursing Facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-evaluation - limited, problem focused (established patient; not post-operative visit) (D0170), intraoral - periapical first radiographic image (D0220) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided October 12, 2021.
You asked the Plan to pay for the problem-focused re-evaluation, intraoral x-ray and localized delivery of antimicrobial agents. You say that you had a medical issue and feel it should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for the intraoral x-ray, and the remaining requested services are 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.
The Plan covers the intraoral x-ray once per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that intraoral x-rays were previously covered on August 30, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-ray has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the problem focused re-evaluation and localized delivery of antimicrobial agents are not among those covered services. Therefore, we decided that the Plan does not have to pay for the re-evaluation - limited, problem focused (established patient; not post-operative visit) (D0170), intraoral - periapical first radiographic image (D0220) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore Test Algorithm (81539) provide on July 29,
2021.
You asked the Plan to pay for the 4Kscore Test Algorithm. You say that you would like reconsideration
because this testing was medically necessary. The Plan denied your request. The Plan says this test is not a
Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the 4Kscore Test Algorithm have not been met. Specifically, the documentation submitted does not
include any clinical information. Without medical records we are unable to determine why this testing was
ordered, how it will affect the member's treatment or if this service meets Medicare criteria for coverage.
Therefore, we decided that the Plan does not have to pay for the 4Kscore Test Algorithm (81539) provide on
July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic images
(D0350) provided on April 1, 2021.
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you would like these
charges to be dropped because you only scheduled a cleaning and never requested x-rays. The Plan denied your
request. The Plan says this service is not a covered benefit under your dental 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 two
dimensional (2D) oral/facial photographic images (D0350) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve steroid injections (64484, 64483).  You asked the Plan to pre-approve the steroid injections. You say that the procedure is medically necessary. The Plan denied your request. The Plan says the injections 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 the steroid injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is is insufficient documentation as to where the epidural steroid injection will be performed and how this procedure fits in with a multi-specialty approach to the pain management of the patient.  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 steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve steroid injections (64484, 64483).
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 services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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 require fifteen hours per week of rehabilitative services and 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit and the ketorolac
tromethamine injection provided on October 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit and the ketorolac tromethamine injection. You
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
services provided are not a covered benefit.
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 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 the hospital outpatient clinic visit and the
ketorolac tromethamine injection provided on October 14, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services provided from March 2, 2021, to March 6, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that code 80999 is not covered.  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. In this case, the case narrative and final determination letter provided by the Plan is regarding the denial of payment for code 80999. However, the Plan has not provided any claims or any type of evidence that this code has been reported or denied for payment. We find that the Plan has not substantiated their reasoning for the denial of payment for the laboratory services provided from March 2, 2021, to March 6, 2021. Therefore, we decided that the Plan has to pay for the laboratory services provided from March 2, 2021, to March 6, 2021.   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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam radiation therapy (77525).  You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy does not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve proton beam radiation therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found while the radiation plan may demonstrate less scatter dose to surrounding structures with protons versus photons (when comparing the calculated dose distributions from planning software), the uncertainty in depth dose, and neutron scatter may negate those differences, and not be reflected in the calculated radiation plan. There is not enough data to support proton therapy for meningioma as an accepted standard for routine care, and the case records/appeal did not sufficiently demonstrate the need for proton therapy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (77525).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (36415, 83036) rendered by the out-of-network (OON) provider on October 27, 2021.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 laboratory services (36415, 83036) rendered by the out-of-network (OON) provider on October 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient services provided on March 8, 2021.  You asked the Plan to pay for outpatient services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. 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. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for outpatient services provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit provided on September 9, 2021.  You asked the Plan to waive the copayment for the PCP office visit. You say that you should not be responsible for a second copayment since the issue was not resolved. 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 $10 copayment for each visit or consultation with your PCP or other primary care provider.   You have been asked to pay a $10 copayment for the PCP office visit. The PCP office visit falls 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 primary care physician (PCP) office visit provided on September 9, 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 not medically necessary.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor sensor (K0553) provided on April 28, 2021.  You asked the Plan to pay for a Freestyle Libre sensor. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the provided medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor sensor (K0553) provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).  

You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this ablation procedure is considered investigational and is non-covered.  

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 radiofrequency ablation 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 considered experimental because of the wide variation in efficacy reported in the literature.         

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 radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for medical supplies provided on September 15, 2021.  You asked the Plan to waive the coinsurance for the medical supplies. You say that you would like to dispute the coinsurance charge of $141.60 The Plan denied your request. The Plan says the proper coinsurance was applied for this service.  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 each Medicare-covered medical supply. The total amount billed was $708 and the coinsurance amount billed was $141.60 ($708 total amount x 20% coinsurance).    You have been asked to pay a 20% coinsurance for the medical supplies. The medical supplies falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 medical supplies provided on September 15, 2021.