Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve physical therapy services. 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. 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 physical therapy services. 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 the enrollee has right knee pain and has been receiving
outpatient physical therapy treatment for weakness, pain and decreased range of motion in the right knee. There
is no documentation that the requested therapy is generally accepted as specific and effective therapy for the
enrollee's condition. The provided medical and therapy notes do not show any results or benefit of the physical
therapy that has been provided thus far. In addition, records do not clarify the etiology of the enrollee's knee
pain in order to determine if physical therapy would generally be accepted as specific and effective therapy for
the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pre-approve physical therapy services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the hip injection procedures you had at an ambulatory surgery center from January 20, 2021, to April 20, 2021.
You asked the Plan to waive the copayments for the hip injection procedures. You say that the hip injections should not be considered surgery. In addition, you say that you were told that the cost sharing for these injections would only be $35. The Plan denied your request. The Plan says you were charged these copayments 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 $255 copayment for services in an ambulatory surgical center. You have been asked to pay a $255 copayment for the hip injection procedures. The facility where you had
these injections is considered an ambulatory surgical center, not a specialist's office. You will see on your bill that the name of the billing provider is a surgical center. That is why the hip injection procedures fall within the services in an ambulatory surgical center 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 copayments for the hip injection procedures you had at an ambulatory surgery center from January 20, 2021, to April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction.
You asked the Plan to pre-approve the extraction. You say that you say that they will not remove your tooth in a dentist office because you are on blood thinners, and your tooth has to come out. The Plan denied your request. The Plan says coverage for the requested service is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an extraction
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interim complete denture (D5810).
You asked the Plan to pre-approve the interim complete denture (D5810). You say that if you don't have any
teeth you will be unable to eat, and your health will be affected. You say that going without dentures for 6
weeks will make you lose more weight and the interim denture is necessary. The Plan denied your request. The
Plan says the service is not a covered benefit.
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 pre-approve the
interim complete denture (D5810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610).
You asked the Plan to pre-approve the therapeutic parenteral drug. You say that you have anxiety and a gag
phobia. You say that you cannot be awake during procedure due to your health issues. The Plan denied your
request. The Plan says therapeutic parenteral drug is not listed as a covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental service is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown
(D2751) and core build up (D2950) for tooth # 19.
You asked the Plan to pre-approve the dental services. You say that according to the Summary of Benefits,
crowns are covered with a $0 copayment. The Plan denied your request. The Plan says porcelain fused to
predominantly base metal crown is not listed as a covered service. The Plan says that core build up is not listed
as a covered service either. The Plan also says that there is 1 type of crown that is covered which is a resinbased
composite crown.
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 porcelain fused to
predominantly base metal crown is not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) and core build
up (D2950) for tooth # 19
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (99213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you have been treated by this provider for twelve years and the provider knows everything that has been going on with your eyes. You would like to continue to see this provider. The Plan denied your request. The Plan says this request cannot be approved unless it is a continuation of care with provider agreeing to the rates.
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 records show that the requested provider declined to accept your current coverage with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with an ophthalmologist (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that it is not safe to be home alone. You say that your physical therapist and hospitalist say that it would be a great benefit for you to have IRF care, as it would help you regain independence and recover. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for noon surgical management of clavicle fracture and pelvic fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) provided on April 20, 2021.
You asked the Plan to pay for intraoperative electroencephalogram (EEG); recording in coma or sleep only (95822). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the clinical value and effectiveness of an intraoperative EEG in the setting of spinal cord stimulator placement to monitor anesthetic depth have not been demonstrated in the peer-reviewed literature.
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 pay for intraoperative electroencephalogram (EEG); recording in coma or sleep only (95822). Our reviewer says that there is an absence of credible literature available at this time that shows that the performance of intraoperative EEG during spinal cord stimulator placement results in clinical improvements or improved outcomes in patients undergoing this procedure. Our physician reviewer found the markedly limited EEG montage used during this type of procedure (2 channels) is not diagnostic in and of itself for any neurological condition. Nor does it provide any significant information to the anesthesiologist or surgeon that can help with the procedure that could not otherwise be provided by equivalent equipment (e.g. a bispectral index measurement). The use of EEG (as billed in this case) would otherwise be considered to investigational and does not meet the Medicare definition of being reasonable and 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 intraoperative electroencephalogram (EEG); recording in coma or sleep only (95822) have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) provided on April 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on May 26, 2021.

You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you feel that the charges are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $285 copayment for diagnostic radiology. 

You have been asked to pay a $285 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 copayment for myocardial perfusion imaging provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical reduction of fibrous tuberosity (D7972).

You asked the Plan to pre-approve the surgical reduction of fibrous tuberosity. You say that you have been waiting to have this procedure done for over three years. You also say that you have been unable to eat a healthy menu because of the need for this procedure. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 pre-approve a surgical reduction of fibrous tuberosity (D7972).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received from May 18, 2021, to May 19, 2021.

You asked the Plan to waive the copayment for the ER services. You say that you do not agree with this copayment because you were informed by the provider that if your stress test came back negative there would not be a copayment. You said that your stress test was negative but were still given a nuclear test. You believe this should be covered in full. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this copayment applies to the ER visit, not to any individual tests you may have received during the visit.

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 $100 copayment for visits to the emergency room.

You have been asked to pay a $100 copayment for the ER services. This copayment applies regardless of the type of services you receive in the emergency room. 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) services you received from May 18, 2021, to May 19, 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 you need inpatient rehabilitation to recover fully and gain strength. The Plan denied your request. The Plan says the criteria for an IRF are not met, and you can receive the necessary care in a less intensive setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that 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: 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 would benefit from the intensive rehabilitation that can be provided at an IRF. Specifically, you would benefit from more occupational and speech therapy to address your cognition and activities of daily living participation, as well as physical therapy to address your persistent balance impairment. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for left temporal epidural hematoma right temporal hemorrhagic contusion, managed conservatively. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for remote pacemaker testing you received from May 8, 2021, to May 11, 2021.

You asked the Plan to waive the copayments for the remote pacemaker testing services. You say that you expected the Plan to pay for these services in full. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amounts for these services ($23.92 for date of service May 8, 2021, and $29.85 for date of service May 11, 2021) were less than your copayment obligation, you are responsible for the full allowed 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 $75 copayment for outpatient diagnostic tests.

You have been asked to pay a $75 copayment for the remote pacemaker testing services. The remote pacemaker testing services fall within the outpatient diagnostic tests 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 copayments for remote pacemaker testing you received from May 8, 2021, to May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SSBCI.

You asked the Plan to pre-approve SSBCI. You say that you would like reconsideration for the requested services. The Plan denied your request. The Plan says you do not have a qualifying diagnosis, do not require intense care coordination and have no high risk of hospitalizations.

The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SSBCI have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve SSBCI.