Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve an upper endoscopy.

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that an upper endoscopy is covered when specific criteria are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has occasional TUMS-responsive heartburn of uncertain onset, as well as right lower quadrant tenderness with change in bowel pattern. She has never undergone an upper endoscopy. An upper endoscopy is considered the standard of care for the enrollee's condition. The upper endoscopy is medically necessary due to age and symptom criteria as well as no prior upper gastrointestinal imaging.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve an upper endoscopy 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve the Keytruda. You say that Keytruda is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says there is no support for Keytruda in the treatment of the member's condition.
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 Keytruda. Our reviewer says that Keytruda is not FDA-approved for the member's diagnosis. Our physician reviewer found Keytruda is not supported by one of the major drug comependia or clinical research for the member'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 the Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided on August 1, 2019. You asked the Plan to pay for the CPAP supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order, valid Proof of Delivery, or valid Delivery Ticket. 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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. The physician order is dated after the date of service and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the CPAP supplies provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on January 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 has network providers available who can provide 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 pathology services provided on January 10, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown for tooth # 13.
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says the crown for tooth # 13 does not meet the criteria for crown replacement.
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 dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested dental service is not medically necessary. Our physician reviewer found the supplied bitewing x-ray does not show the distal margin of the crown, and the mesial though showing an open margin does not show any obvious decay. Based on the documentation provided it cannot be inferred there is any breakdown of the margin despite the poor marginal fit which would require replacement. The reviewer found that given the appearance of the crown on the one provided x-ray there does not appear to be a necessity for replacement of the crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT Scans of the abdomen and pelvis (74176).
You asked the Plan to pre-approve the CT Scan. You say that the CT Scan is medically necessary because the member is losing weight and has loose stools and bloating. The Plan denied your request. The Plan says there are other tests that can be done to look for a cause of the member's symptoms.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that the documentation does not support that a CT of the abdomen and pelvis is currently medically necessary or reasonable. Our physician reviewer found the physical examination notes no abdominal tenderness or masses and the laboratory evaluations have been non-actionable. 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 CT Scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT Scans of the abdomen and pelvis (74176).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided to the enrollee from September 20, 2019 to September 27, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims. Therefore, we decided that the Plan does not have to pay for home infusion services provided to the enrollee from September 20, 2019 to September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plandenied your request. The Plan says this is 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the standard for defining a positive block is greater than 80% pain relief. This was not achieved. Therefore, the requested procedure 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea lumbar/sacral facet joint block for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 3, 2019 to October 31, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsiderationbased on the records submitted.The Plan denied your request. The Plan says the procedure code/type of bill is inconsistent with the place of service.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, this claim as been submitted with an inappropriate type of bill..Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 3, 2019 to October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train-of-four (TOF) testing provided during intraoperative neuromonitoring (IONM) on June 21, 2019 billed with CPT code 95999.You asked the Plan to pay forthe TOF testing. You say that this cannot be denied as not medically necessary since the treating physician deemed it to be necessary.The Plan denied your request. The Plan says all services were paid aside from the code 95999 which was denied as included in payment for the other billed services.The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code. IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service.Therefore, we decided that the Plan does not have to pay forthe train-of-four (TOF) testing provided during intraoperative neuromonitoring (IONM) on June 21, 2019 billed with CPT code 95999.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you have used all of your 100 SNF days for this benefit period.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from December 31, 2019 through January 28, 2020, February 3, 2020 through February 21, 2020 and February 25, 2020 through April 18, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 19, 2019 through September 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 19, 2019 through September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation and prophylaxis provided by an OON provider on October 31, 2019.You asked the Plan to waive the coinsurance for the periodic oral evaluation and prophylaxis. You say that this dentist is out-of-network. You also say since the facts have not changed, you are requesting a refund.The Plan denied your request. The Plan says they paid your claim at 100% of the allowed amount, rather than assessing 30% coinsurance. The Plan also says that you are responsible for the difference between the billed amount and the allowed amount.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, you must pay a 30% coinsurance for Non-Medicare covered preventive dental services received by an out-of-network provider.The record shows that you received these services from an out-of-network provider, and the Plan paid 100% of the allowed amount, which is the in-network rate.Therefore, we decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation and prophylaxis provided by an OON provider on October 31, 2019.If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6059).You asked the Plan to pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6059). You say that there is a medical and dental necessity to finish the implant prosthetic treatment. You say that the treatment should be approved.The Plan denied your request. The Plan says these are not covered 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 pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6059).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 8, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that she still had pneumonia from the first stay. You say that she should not have been transferred to the skilled nursing facility. The Plan denied your request. The Plan says the copayment applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for each one-way Medicare-covered ambulance trip. The enrollee has been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that the enrollee was transported by ambulance to the hospital. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the bitewing x-rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-rays (D0230 x 4) provided on December 5, 2019.
You asked the Plan to pay for the dental services. You say that without the x-rays, the dentist would not have seen the cavities. You also say that they advised that they accepted your insurance. The Plan denied your request. The Plan says the dental services that you received are not listed as covered. The Plan also says any services not listed are 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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the bitewing x-rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-rays (D0230 x 4) provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a POV is covered when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee is ambulating short distances with a cane with difficulty and has pain in both knees from osteoarthritis. He is able to use a manual wheelchair and power wheelchair in the home. The POV is being requested to improve mobility in the home and community. He does not meet the criteria for coverage of a POV, as he has a manual and power chair with which he is functional at home in his home. The POV is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. The file shows that the POV is also being requested for use outside of the home. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on June 15, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on June 15, 2019.