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

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on January 25, 2020.You asked the Plan to pay for the endodontic therapy. You say that you were never informed of the cost of this procedure. You also say that you live on a small social security check.The Plan denied your request. The Plan says the cost share was applied correctly.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 are responsible for a 50% coinsurance for the listed endodontic, periodontic, and oral surgery services.Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on January 25, 2020.Your complaint about feeling that you were scammed 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) services.
You asked the Plan to pre-approve the PET scan. You say that the medical notes support the medical necessity of the requested PET scan. The Plan denied your request. The Plan says the records show the same study or a test like it has been done for the enrollee. The Plan says that the prior study showed the doctor was they needed to see in order to treat the enrollee's condition. The Plan says that repeat imaging is not supported without the results of the prior imaging that shows a clear reason for it.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a nonischemic cardiomyopathy with no documented chest pain, no documented ischemic ECG changes and a recent reportedly "negative" stress echo October 14, 2019. The documentation does not support the medical necessity for additional stress testing including the nuclear stress test that was performed on May 21, 2020. Since there is no documented indication for stress testing the records do not support the medical necessity for a cardiac PET scan. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5298) purchased January 8, 2020 from an out
of network provider.
You asked the Plan to pay for the hearing aids. You say that you were told that if the provider didn't order the
hearing aids for your she would not be able to adjust or service hearing aids purchased outside of her office.
You followed instructions in the benefits plan. The Plan denied your request. The Plan says enrollee's must
receive their services from an in-network hearing provider.
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 for
hearing aids only when purchased from an in-network provider. Before receiving hearing services, you must
contact the Plan to register.
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
hearing aids (V5298) purchased January 8, 2020 from an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on January 10, 2018.You asked the Plan to pay forthe ambulance services. You say that you did not know the provider filed the claim untimely.The Plan denied your request. The Plan says the claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance services was not filed until April 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 10, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on March 13, 2020.You asked the Plan to pay forthe self-administered drugs. You say that these drugs were administered during an emergency room visit for a broken arm.The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided on March 13, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services.
You asked the Plan to pre-approve SNF care. You say that the SNF services are medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 this patient does not require the necessary
services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
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 Skilled Nursing Facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73120) provided December 19,
2019.
You asked the Plan to waive the copayment for the x-ray. You say that you were told there was no copayment.
The Plan denied your request. The Plan says the correct copayment was applied per the Evidence of Coverage.
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 $35
copayment for Radiology Services.
You have been asked to pay a $35 copayment for the x-ray. The x-ray falls within the Radiology Services
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 an x-ray (73120) provided
December 19, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99213) provided on January 13, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records
submitted.` The Plan denied your request. The Plan says that CPT code 99213 is a component of column I code
11721 and the documentation does not support that 99213 is a significant and separately identifiable service.
The Plan must follow Medicare rules. Medicare rules say that column one/column two codes are code pairs that
should not be reported together.
We find that CPT code 99213 is supported in the record. Specifically, Per NCCI edits, 99213 is not a column II
code to CPT code 11721. The NCCI edit bundling these two codes was terminated prior to the date of service.
Based on this information, we decided that Medicare rules for coverage of the office visit have been met.
Therefore, we decided that the Plan has to pay for an office visit (99213) provided on January 13, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 above are met. Custodial care is not covered.We asked our physician reviewerto 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 you do not require skilled nursing or therapy services on a daily basis. You do 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-approveskilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Hydrogel dressing provided on September 27, 2019.
You asked the Plan to pay for Hydrogel dressing (A6248). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an enrollee. Records show that Hydrogel dressing was used in a SNF . The facility must furnish all necessary covered supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies would have been included in the global payment submitted to the plan by the facility. If the health plan is not covering the SNF stay, the cost of these supplies is absorbed by the facility. Therefore, we decided that the Plan does not have to pay for Hydrogel dressing provided on September 27, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pay forProcrit injection services (HCPCS J0885) provided to the enrollee from January 2, 2020 to January 23, 2020.You asked the Planto pay forthe services. You say that the appropriate modifier was missing.The Plandenied your request. The Plansaysthata corrected claim was sent.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. A review of the file shows that the provider used modifier -EC on the claim. The Local Coverage Article that is valid for this case allows the use of modifier EC. The plan has not substantiated their denial, as it it appears that the provider has been adequately following Medicare guidelines on the claim.Therefore, we decided that the Planhas to pay forProcrit injection services (HCPCS J0885) provided to the enrollee from January 2, 2020 to January 23, 2020.If the Plandoes 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/orsend 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group 3 power wheelchair with accessories.You asked the Plan to pre-approvea group 3 power wheelchair with accessories. You say that the items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered if specific criteria is 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 a group 3 power wheelchair with accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not support that your mobility limitation is due to a neurological condition, a myopathy or a congenital/skeletal deformity therefore per Medicare Guidelines you do not meet criteria for the Group 3 power wheelchair. Your mobility limitation is from your amputation and there is no evidence of hemiparesis or weakness due to the stroke on the submitted notes. Additionally, the documentation indicates your strength in the upper extremities and function is sufficient to be able to control any power options on a wheelchair through their own switches therefore there is no indication for an expandable controller, harness and accessories.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 group 3 power wheelchair with accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea group 3 power wheelchair with accessories.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar spine MRI.
You asked the Plan to pre-approve a lumbar spine MRI. You say that the requested lumbar spine MRI is medically necessary. The Plan denied your request. The Plan says the requested lumbar spine MRI is 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 a lumbar spine MRI. Our reviewer says that the requested lumbar spine MRI is not medically necessary. Our physician reviewer found the enrollee is diagnosed with causalgia of bilateral lower limbs. The records do not show a recent trial and failure of physical therapy. The requested MRI is not needed at this time. 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 lumbar spine MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spine MRI.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown lengthening (D4249) and drugs or medicaments (D9630) provided on February 3, 2020.
You asked the Plan to pay for the crown lengthening (D4249) and drugs or medicaments (D9630). You say that the tooth was permanently repaired. You say that the procedure is covered. The Plan denied your request. The Plan says the services 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 pay for the crown lengthening (D4249) and drugs or medicaments (D9630) provided on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the needed care can be safely given in a lower 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 above.We asked our physician reviewer to carefully review thecase 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approveacute 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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an 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: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment forthe PSA test provided on April 29, 2019.You asked the Plan to waive the copayment forthe PSA test. You say that you had cancer in the past and you say a PSA test is covered once yearly. You say you would like the claim to pay with the $0 copayment due to your medical history. The Plan denied your request. The Plan says that the additional medical records show that the specific antigen service was not related to a screening.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit medical records to support that the PSA service was not related to a screening. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment forthe PSA test provided on April 29, 2019.