Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 65-year-old female with breast cancer, end stage renal disease, low back pain and weakness. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy, Opdivo, ondansetron HCl, metoclopramide HCl, and methprednisolone.
You asked the Plan to pre-approve the requested drug regimen. You say that the requested regimen is medically necessary to the enrollee's treatment. The Plan denied your request. The Plan says the requested regimen is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 requested drug regimen. Our reviewer says that the requested drug regimen of Yervoy, Opdivo, ondansetron HCl, metoclopramide HCl, and methprednisolone is not medically necessary. Our physician reviewer found requested regimen of Yervoy, Opdivo, ondansetron HCl, metoclopramide HCl, and methprednisolone is not FDA-approved for the enrollee's diagnosis after progression of disease on prior PD-L1 therapy. The reviewer found that the requested regimen is not supported by any of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested drug regimen 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 the requested drug regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy, Opdivo, ondansetron HCl, metoclopramide HCl, and methprednisolone.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic ultrasound provided on November 29, 2020.
You asked the Plan to pay for the diagnostic ultrasound. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 23, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for a diagnostic ultrasound provided on November 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home blood pressure device described by current procedural terminology (CPT) code A4660 provided on August 5, 2020.
You asked the Plan to pay for a home blood pressure device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a home blood pressure device is not covered by Medicare or the Plan for your condition.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pay for a home blood pressure device described by current procedural terminology (CPT) code A4660 provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
pneumonia and chronic low back pain. The enrollee is not intubated/ventilated. There is no evidence that the
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the
same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at
the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged
to a lower level of care for any ongoing long-term care needs.
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140) provided on October 8, 2020.

You asked the Plan to pay for the limited evaluation. You say that this service was urgent and necessary and should be covered. The Plan denied your request. The Plan says this type of evaluation is not covered by the Plan's supplemental dental 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 pay for the limited (problem-focused) oral evaluation (D0140) provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone grafting services and periradicular surgery (D3428) under the medical benefit instead of the dental benefit.
You asked the Plan to provide coverage for dental services under your medical benefit instead of the dental benefit. You say that you prefer to have these services covered under your medical benefit. The Plan denied your request. The Plan says these services are being ordered by a dental professional and are considered dental services. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the Plan did not deny coverage for these services under the dental benefit. The Plan denied coverage for these services under the Medicare Part B benefit as they do not qualify as traditional Medicare covered medical services.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. These services were ordered by a dental professional under a dental code. These services would not be covered under your Medicare coverage benefit. The Plan indicates these services would be covered under the dental benefit up to $1000 if submitted appropriately by your provider. Therefore, we decided that the Plan does not have to provide coverage for bone grafting services and periradicular surgery (D3428) under your medical benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to further pay for rental of durable medical equipment provided
December 15, 2019, to January 18, 2021.
You asked the Plan to further pay for rental of durable medical equipment. You say that you would like these
claims reprocessed. The Plan denied your request. The Plan says these claims have processed correctly, and no
reimbursement is due.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for durable medical equipment.
You have been asked to pay a 20% coinsurance for rental of durable medical equipment. These services fall
within the durable medical equipment 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 further pay for rental of
durable medical equipment provided December 15, 2019, to January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 27, 2021.
You asked the Plan to pay for the dental services. You say that your coverage shows no copay for visits and a cleaning once every 6 months. You say that you understand there is a $50 deductible yearly for in and out of network services. You also say that you were only paid $60 for a $157 bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that providers are paid based on Maximum Allowable Charge (MAC). The Plan also says that out of network providers may you still bill you for any amount greater than the MAC payment made by the plan to the provider.
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 and the services are listed as covered, dental services performed out of network may have a higher cost share. The Evidence of Coverage clearly states that out of network providers may you still bill you for any amount greater than the MAC payment made by the plan to the provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a digital hearing aid (V5261) and dispensing fee (V5160) provided on January 4, 2021.
You asked the Plan to pay for the hearing aid and dispensing fee. You say that you feel the dispensing fee should be covered with the hearing aid fitting/evaluation and the Plan should pay more for the hearing aid. The Plan denied your request. The Plan says the dispensing fee is not a covered service under your hearing aid benefit. The Plan has paid the full $750 allowed for the hearing aid and accessories (ear mold inserts (V5265)).
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to $750 per year for hearing aids. You are responsible for any costs beyond this Plan limit. This benefit also includes one routine hearing exam and one hearing aid fitting/evaluation.
We looked at the file and the Plan's rules. The Plan has paid the full $750 allowed for the hearing aid and ear mold inserts. The dispensing fee is not listed as a covered service under this benefit. Based on this information, we decided that the Plan's rules for coverage of the hearing aid and dispensing fee have not been met. Therefore, we decided that the Plan does not have to pay any additional amount for the digital hearing aid (V5261) or cover the dispensing fee (V5160) provided on January 4, 2021.
Your complaint about the cost of non-covered services provided by a contracted provider and what the Plan is able to cover under the supplemental benefit 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 provide additional payment for the ophthalmological services: medical examination and evaluation (92014) and determination of refractive state (92015) provided October 10, 2020.
You asked the Plan to provide additional payment for the eye exam and vision test. You say that you were unaware your provider was out-of-network (OON) and you cannot afford the extra cost. The Plan denied your request. The Plan says the vision benefit allowance has been correctly applied. You are responsible for the additional cost charged by the OON provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to the $75 plan allowance. We looked at the file and the Plan's rules. In this case you received a routine eye exam and vision test from an
OON provider. The Plan provided payment up to the $75 plan allowance. Based on this information, we decided that the Plan does not have to provide additional payment for the ophthalmological services: medical examination and evaluation (92014) and determination of refractive state (92015) provided October 10, 2020.
Your complaint about being unaware that your vision provider was OON 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the all-lower extremity prostheses, flex-walk system or equal (L5981).
You asked the Plan to pre-approve the prostheses. You say that the enrollee has lost roughly 60 lbs. since she was initially fit with this style of feet in 2010. Because of the weight loss the feet are not too stiff and do not provide adequate ground compliance. The Plan denied your request. The Plan says the requested service is not medically necessary and appropriate for the enrollee.
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 Criteria for flex-foot orthosis not met. The records do not show a functional level of 3 or above for the patient. The patient's level of function is too low for the advanced orthosis.pre-approve the prostheses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for flex-foot orthosis has not been met. The records do not show a functional level of 3 or above for the enrollee. The enrollee's level of function is too low for the advanced orthosis.
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 prostheses have not been met. Therefore, we decided that the Plan does not have to pre-approve the all-lower extremity prostheses, flex-walk system or equal (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5211) and partial lower denture (D5212) provided on June 24, 2020.
You asked the Plan to pay for the dentures. You say that you were led to believe that these dentures would be covered at no cost to you and that they had been approved. You say you did not know that you had a $1,000 dental allowance. The Plan denied your request. The Plan says that $950.30 had been paid for comprehensive services in 2020. You have a maximum allowance of $1,000 for supplemental comprehensive dental services. You are responsible for any charges that exceed this amount. The Plan paid the remaining $49.70 and part of the billed cost of these dentures was written off, but you are still responsible for the remaining $1,329.
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 will pay up to a maximum of $1,000 for comprehensive dental services per year. Members are responsible for all costs over and above this allowance amount. Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive services provided in excess of the $1,000 dental benefit maximum are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5211) and partial lower denture (D5212) provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective lens coating (V2750) provided on
September 23, 2020.
You asked the Plan to pay for the anti-reflective lens coating. You say that as a senior citizen, road/sun glare during the day and headlight glare at night can be a challenge. You say that you added the coating because you considered it an aid to your safety and to any other senior who drives. The Plan denied your request. The Plan says the medical record reviewed does not show that medical necessity is documented by the treating practitioner.
Medicare generally does not cover routine eyewear services. Medicare rules say anti-reflective coating (V2750) is covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner. We looked at the file and the Medicare rules. Medicare says anti-reflective coating (V2750) is covered only when medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner. The file does not show that the treating provider billed or documented the medical necessity for the anti-reflective coating. Therefore, we decided that the Plan does not have to pay for anti-reflective lens coating (V2750) provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed services were not urgent, emergent, referred by the member's primary care physician or approved by the Plan.
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 laboratory services provided on June 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical placement of implant body (D6010) provided on October 6, 2020.
You asked the Plan to pay for the surgical implant. You say that this was a necessary service, and you are unsatisfied with the services covered by the Plan. The Plan denied your request. The Plan says this service is not covered by the Plan's supplemental dental 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 a surgical placement of implant body (D6010) provided on October 6, 2020.