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

We decided that the Plan does not have to pay for the intraoral complete series of radiographic images.

You asked the Plan to pay for the intraoral complete series of radiographic images. You say that you did not know the service would not be covered. The Plan denied your request. The Plan says there is no coverage for D0210 intraoral complete series of radiographic images.

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 intraoral complete series of radiographic images.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for the acute inpatient admission for a total shoulder arthroplasty.

You asked the Plan to pre-approve for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.

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 pre-approve 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 enrollee has a history of osteoarthritis, prior shoulder surgeries, hypertension, prediabetes, hyperlipidemia, and sleep apnea. There is no indication from the provided notes that the enrollee requires inpatient services or a prolonged recovery for this procedure. It is not expected that the enrollee will require hospital services that would likely cross 2 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 pre-approve for the acute inpatient admission for a total shoulder arthroplasty.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee
was in hospice on this date of service.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and the complete
series x-ray (D0210).

You asked the Plan to pay for the dental services. You say that your primary dentist is not in network. You say
that they advised some of the bill should be covered. You say that you had x-rays taken. You say that you
decided to find an in network dentist. You also say that the services should be covered on the grounds that your
previous dentist said that some of the bill would be paid. The Plan denied your request. The Plan says the
provider in this case is out of network. The Plan says that preventive dental services are not covered out of
network.

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 services you received are
considered preventive. The Evidence of Coverage clearly states that preventive dental services are not covered
out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam
(D0150) and the complete series x-ray (D0210).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for Skilled Nursing Facility services.

You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration because this service was reported correctly. The Plan denied your request. The Plan says that the service dates don't match the number of units billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that the Skilled Nursing Facility services are supported in the record. Specifically, the claim indicates that this period was 8 days and 8 units were billed. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility services have been met. Therefore, we decided that the Plan has to pay for Skilled Nursing Facility services.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial dentures (D5211 and D5212).

You asked the Plan to pre-approve the partial dentures. You say that you would like reconsideration because these teeth should not be pulled. The Plan denied your request. The Plan says there is 1 or more teeth that are not healthy enough to support this service.

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 partial dentures 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 partial dentures. Our reviewer says that the documentation insufficient to demonstrate that a Maxillary partial denture, resin base, and a Mandibular partial denture, resin base are medically reasonable and necessary. Our physician reviewer found it is not clear that your remaining teeth are currently healthy enough to allow for upper and lower partial dentures.

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 partial dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial dentures (D5211 and D5212).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 the records show you were admitted to the acute care hospital with respiratory failure and sepsis requiring mechanical ventilation and antibiotics. You have been weaned from the ventilation support and antibiotics completed but you require basic wound care and oxygen weaning. The records show you are improving. The records do not show that you require services at the LTACH that are not already available at the current facility. Medicare coverage criteria for transfer are not met. 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.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit (99283).

You asked the Plan to waive the copayment for an emergency department visit. You say that you should not have to pay the copayment because it was not your choice to go the emergency room. The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care.

You have been asked to pay a $90 copayment for an emergency department visit. The service at issue falls within the emergency care 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 emergency department visit (99283).
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 this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 the medical records show the enrollee appears to be stable and improving gradually and should only require short-term additional acute care services which can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Medicare coverage criteria for transfer are not met. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a delivery charge (A9901) for DME.

You asked the Plan to pay for a DME delivery charge. You say that there is not any contracting DME supplier
in your area and you feel the delivery charge should be covered. The Plan denied your request. The Plan says
rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that sales tax and shipping charges are not separately
payable by Medicare.

The request is for a waiver of shipping charges. Based on this information, we decided that Medicare rules for
coverage of a DME delivery charge have not been met. Therefore, we decided that the Plan does not have to
pay for a delivery charge (A9901) for DME.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a revascularization procedure on the right lower extremity.
You asked the Plan to pre-approve the revascularization procedure. You say that you would like reconsideration because the member has a non-healing wound. The Plan denied your request. The Plan says that the documentation fails to indicate that the requested procedure meets NCD criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 revascularization procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found percutaneous transluminal angioplasty is nationally covered for treatment of atherosclerotic obstructive lesions in the lower extremities. 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 revascularization procedure have been met. Therefore, we decided that the Plan has to pre-approve a revascularization procedure on the right lower extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that this is medically
necessary. The Plan denied your request. The Plan says this would exceed the enrollee's needs.
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 a MyoPro Motion G Orthotic device.
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case.
Our physician reviewer found the MyoPro Orthosis is not the most appropriate available supply or level of
service for the patient in question considering potential benefits to the patient. It is not known to be effective,
based on scientific evidence, professional standards and expert opinion, in improving health outcomes. 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 her hemiparetic arm
function, or be safe for long term use. There is insufficient evidence in the literature that this device will
increase her 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 a MyoPro Motion G Orthotic device have not been met. Therefore, we decided
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 15, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
Plan is unable to determine if the beneficiary met medical necessity with the information provided since the
provider did not respond to medical record requests.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to
justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
physician's services have not been met. Therefore, we decided that the Plan does not have to pay for physician's
services provided on July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on November 18, 2020.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 surgical pathology services provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit provided on November 10, 2020.
You asked the Plan to pay for a clinic visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 a clinic visit provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 24,
2020.
You asked the Plan to waive the copayment for office visit. You say that you did not know that the Plan
changed your Primary Care Provider (PCP). The Plan denied your request. The Plan says the copayment
amount you are being charged is correct.
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 $45
copayment for specialist office visit.
You have been asked to pay $45 copayment for office visit. Office visit falls within the Physician/Practitioner
Services, including Doctor's Office Visits 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 office visit provided on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Computed tomography (CT) scan of thorax (71250) provided November 9, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the service should be considered follow-up care with no cost-sharing applied. The Plan denied your request. The Plan says the cost-share was 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). Your contract with the Plan clearly says that you must pay a $250 copayment per day for Medicare-covered diagnostic radiology services. You have been asked to pay a total of $131.37 copayment for the CT scan. This service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 the Computed tomography (CT) scan of thorax (71250) provided November 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because
you are not able to do anything on your own. The Plan denied your request. The Plan says you do not meet the
medical necessity criteria for SNF admission.
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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you do not require skilled services
on an inpatient basis in an SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve the SNF admission.