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

We decided that the Plan does not have to pay for the panoramic x-ray and 8 resin-based composites provided on March 4, 2020, and May 7, 2020.
You asked the Plan to pay for the panoramic x-ray and resin-based composites. You say that you would like these services to be covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.
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, full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a complete series of intraoral x-rays on March 4, 2020 and your full mouth or panoramic x-rays benefit has been exhausted. The contract also says that restorations are limited to two procedures per calendar year. The record shows that you received 10 resin-based composites on May 7, 2020, two of which were covered by the Plan, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and 8 resin-based composites provided on March 4, 2020, and May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not have an illness that is complex enough to require further hospital 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. The patient is currently undergoing treatment at an acute care hospital (ACH) for multi-focal trauma. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is tolerating ventilator weaning. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 22, 2020, to April 22, 2020.
You asked the Plan to pay for the home health services. You say that the provider is not required to be enrolled in Medicare. The Plan denied your request. The Plan says the services were rendered by a provider who is not licensed with Medicare, and is not eligible to be paid for the service on the date it was provided.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. The services were rendered by a provider who is not eligible to provide services under Original Medicare. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from January 22, 2020, to April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on December 3, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says payment is not allowed for providers who opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The testing at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the testing services provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on October 26, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you were told that copayments were being waived. The Plan denied your request. The Plan says the correct copayment has been applied.
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 physician/practitioner services/in-network/specialist. You have been asked to pay a $35 copayment for specialist services. Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on October 26, 2020.
We note your complaint that a customer service representative from the Plan that you were not responsible for the copayments for the rest of the year. Your complaint about the Plan's customer service is a grievance that must be answered by the Plan. Medicare does not permit us to address these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility services.

You asked the Plan to pre-approve the Skilled Nursing Facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 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 the Skilled Nursing Facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that the enrollee requires the services on a daily basis 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 Skilled Nursing Facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on January 22, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 comprehensive periodontal evaluation (D0180) provided on January 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.
You asked the Plan to pay for the ambulance services. You say that you were recovering from Covid and following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic medial branch blocks.

You asked the Plan to pre-approve the thoracic medial branch blocks. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the records show that your first medial branch block injection only provided 50% pain relief for 1 week.

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 thoracic medial branch blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found your previous blocks produced one week of 50% pain relief. The request does not meet the criteria for a successful block. 

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 thoracic medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve thoracic medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy of an anterior tooth (D3310) and endodontic therapy of a premolar tooth (D3320) provided on December 2, 2020.

You asked the Plan to pay for the endodontic therapies. You say that the provider submitted a dental estimate for bridges, and your Plan processed it as a claim in error. The Plan denied your request. The Plan says your comprehensive dental allowance for the 2020 calendar year has been fully 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, the Plan offers up to a $1,000.00 allowance for comprehensive dental services every quarter. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on December 8, 2020 and your annual maximum benefit has been exhausted. The record shows that the claim for the bridges has been adjusted/corrected from a $3,940 payment to a $0.00 payment, and is not considered in the total benefits for 2020. Therefore, we decided that the Plan does not have to pay for the endodontic therapy of an anterior tooth (D3310) and endodontic therapy of a premolar tooth (D3320) provided on December 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to apply in-network coverage for the medical services provided between October 22, 2019, through January 14, 2021 by an out of network (OON) provider.
You asked the Plan to apply in-network coverage for the OON medical services. You say that you chose to be treated by the OON provider based on which provider had the best medical outcomes. You were told by doctors that if you had been treated by a network provider, your cancer would have returned, and your spinal surgery would have been ineffective. The Plan denied your request. The Plan says it was decided to provide in-network coverage for the outpatient surgery on March 5, 2020 and for the inpatient hospital stay provided from March 9 through March 29. All other services could have been provided by network providers and are correctly covered at OON cost sharing rates.
Medicare rules say that plans can require enrollees to get care from network providers in order to obtain in-network cost sharing rates. The contract with the Plan says that the Plan has to apply in-network coverage 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 network coverage the item/service at issue, nor was a request made for such prior approval. We found no exception that would require the Plan to apply in-network coverage for these items/services. Therefore, we decided that the Plan does not have to apply in-network coverage for the medical services provided between October 22, 2019, through January 14, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that these services were provided in a skilled nursing facility. You say that these services were medically necessary. The Plan denied your request. The Plan says requires the utilization of in-network providers unless the plan pre-approves out of network services in non-emergent situations. The Plan says that prior authorization was not 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 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 psychotherapy services provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2020, by
an OON provider.

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 services were rendered by an out-of-network provider without prior authorization.

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 December 23,
2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care services.
You asked the Plan to pre-approve wound care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that wound care is 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 wound care services. Our reviewer says that the documentation does not support that the requested wound care services are medically reasonable or necessary. Our physician reviewer found you have chronic venous stasis ulcers and has recently undergone ablation. The record indicates the wounds are improving. The record does not indicate failure of standard therapy. Therefore, you do 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 wound care services have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device has deluxe features that exceed medical need and replaces, rather than improves the function of the arm.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the two periodontal scalings and root planings and crown, or pay for the core buildup, including any pins when required and endodontic therapy provided from October 28, 2020, to November 19, 2020.

You asked the Plan to pay for the periodontal scalings and planings, crown, core buildup, and endodontic therapy. You say that you believe these services should be covered. The Plan denied your request. The Plan says the core buildup and endodontic therapy are not covered services. The Plan also says that the in-network benefit rates have been paid for the scalings and planings and crown.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup and endodontic therapy are not among those covered under this benefit. Periodontal scaling and root planing and crown are covered benefits, and you are responsible for a 70% coinsurance for each. Therefore, we decided that the Plan does not have to pay more for the two periodontal scalings and root planings and crown, or pay for the core buildup, including any pins when required and endodontic therapy provided from October 28, 2020, to November 19, 2020.