Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the oral exam (D0120), cleaning (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230 x 2).

You asked the Plan to pay the in network rate for the 2 additional periapical x-rays. You say that you went to see this provider. You say that they were an in network provider. You say that now, 6 months later, you are being told that this provider is no longer in network. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit for this service has been exhausted.

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 periapical x-ray is listed as a covered service, the frequency limit of 1 per calendar year has been exhausted. The record shows that the Plan paid for the initial periapical x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay the in network rate for the oral exam (D0120), cleaning (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230 x 2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic resonance imaging (MRI) of the cervical
spine and lumbar spine
You asked the Plan to pre-approve MRI. 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. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
documentation does not support that the requested MRI services are medically reasonable or necessary. Our
physician reviewer found the enrollee has a history of sciatica and lumbago. The enrollee was seen by his
chiropractor in January 2021 and found to have ankle, shoulder, thumb, and low back pain. The enrollee has a
previous fusion at C4-C5 and degenerative disc disease at C5-C7. The provider has established a diagnosis and
treatment plan. The enrollee is progressing towards those goals. Therefore, the enrollee does not meet criteria
for the requested 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 MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve Magnetic resonance imaging (MRI) of the cervical spine and lumbar spine
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an LTACH for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another setting, such as acute
rehabilitation facility, skilled nursing facility, outpatient setting, or home care.

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 there is no documentation of multiple unsuccessful weaning attempts. There is no
documentation that the enrollee is capable of being weaned at this time. There is no documentation provided
necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care
hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital
where she is currently receiving care. There are no services available at the LTACH that the enrollee requires
that are not available at the health care setting being offered by the health plan. The requested LTACH services
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and
able to be furnished safely and effectively only on an inpatient basis.

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 admission to an LTACH for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four Pontics and two retainer crowns.

You asked the Plan to pay for the Pontics and retainer crowns. You say that you were advised that a portion of these services would be covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify 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 four Pontics and two retainer crowns.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.

You asked the Plan to pre-approve an automatic blood pressure monitor. You say that this item is necessary for your condition. The Plan denied your request. The Plan says a device used to measure blood pressure is not covered.

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 pre-approve an automatic blood pressure monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for the inpatient services. You say that the enrollee's symptoms were worsening. The Plan denied your request. The Plan says the enrollee did not have a stroke, bacteria in the blood, kidney infection, fever, or blockage of urine flow.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 the inpatient services. Our physician reviewer found that the enrollee presented to the emergency room with confusion and a urine infection. He was treated with antibiotics. The record does not show that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient.
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 enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 acute on chronic respiratory failure and a urinary tract infection. She was discharged to a skilled nursing facility on 3/30/21. 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99212) for dermatology services to be provided by an OON provider.

You asked the Plan to pre-approve an office visit for dermatology services. You say that the enrollee was unaware of your out of network status with the Plan. The Plan denied your request. The Plan says rules for OON services have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99212) for dermatology services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supply allowance billed for date of service November 20, 2020.
You asked the Plan to pay for the CGM supply allowance. You say that the medical records support the need for these items. The Plan denied your request. The Plan says the medical records does not clearly support medical necessity. In addition, however, there was no copy of the written order nor of proof of delivery for these items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or proof of delivery. 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 the continuous glucose monitor (CGM) supply allowance billed for date of service November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve a power scooter. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The documentation does not support that your condition cannot be improved by a walker, cane or manual wheelchair and does not support that you can safely operate the PMD being requested. No documentation of a home assessment was provided. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a brain positron emission tomography (PET).

You asked the Plan to pre-approve a brain PET. 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 follows Medicare rules. Medicare rules say that brain PETs are only covered for certain indications. 

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 brain PET. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the office visit note provided for review indicates that the member most likely has an Alzheimer's Disease based pathology. The documentation does not support that the enrollee meets diagnostic criteria for Alzheimer's disease (AD) and fronto-temporal dementia (FTD). Therefore, the requested services are not medically 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 brain PET have not been met. Therefore, we decided that the Plan does not have to pre-approve a brain positron emission tomography (PET).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 15, 2020 to June 18, 2020.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, claims are required to be billed on the Original Medicare form which is CMS-1450. This claim was not billed on the appropriate claim form. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 15, 2020 to June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.
You asked the Plan to pre-approve the dental implants. You say that you would like the dental implants to be approved for coverage. The Plan denied your request. The Plan says the requested service is not a Medicare 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 dental implants.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).

You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says this drug 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 FDAapproved
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 Retacrit. Our reviewer says that
Retacrit (Q5106) is not medically reasonable and necessary for the enrollee. Our physician reviewer found
based on the medical records provided and the Medicare-approved major drug compendia, there is no
documentation that the requested use of Retacrit is FDA-approved for the enrollee's diagnosis/clinical scenario.
The records do not document that the enrollee is receiving any active anti-rheumatic treatment or that her
hemoglobin level is less than 11 grams per deciliter (grams/dL). Our reviewer found that the use of Retacrit is
not supported by one of the major drug compendia or by clinical research that appears in a Centers for
Medicare & Medicaid Services approved medical journal. Our physician reviewer also found that the use of
Retacrit is not supported for this enrollee's diagnosis/clinical scenario.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit (Q5106).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the new patient office visit (99202), x-ray of the lower sacral spine (72110), electrical stimulation (G0283), and the application of hot or cold packs therapy (97010) provided from October 16, 2020, through October 26, 2020.
You asked the Plan to issue reimbursement 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 these services are not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to issue reimbursement for the new patient office visit (99202), x-ray of the lower sacral spine (72110), electrical stimulation (G0283), and the application of hot or cold packs therapy (97010) provided from October 16, 2020, through October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612).
You asked the Plan to pre-approve the therapeutic parenteral drugs. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 therapeutic parenteral drugs (D9612).