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

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation, two dental surgery procedures, and moderate sedation services, problem focused limited oral evaluation, and endodontic therapy provided from July 29, 2019 to August 20, 2019.
You asked the Plan to pay for the bone replacement graft, two dental surgery procedures, moderate sedation services, problem focused limited oral evaluation, and endodontic therapy. You say that the codes on this claim were old codes. You also say that the codes that were used were supposed to be transferred to medical codes. The Plan denied your request. The Plan says these services were dental in nature, and not covered benefits per Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation, two dental surgery procedures, and moderate sedation services, problem focused limited oral evaluation, and endodontic therapy provided from July 29, 2019 to August 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from October 26, 2019 through November 1, 2019.

You asked the Plan to waive the copayment for the SNF stay. You say that there was no medical reason to stay. You say that you are appealing the final three days. 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). Your contract with the Plan clearly says that you must pay a $170.50 copayment per day for days 21 through 100.

You have been asked to pay a $1,023 copayment for the SNF stay. 

Date of Service	Number of SNF Days	Standard Copayment	Member Liability
October 26, 2019- November 1, 2019	6	$170.50/day	$1,023

The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The records show that you were an inpatient for 6 days. 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 SNF stay provided from October 26, 2019 through November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvethe scooter. You say that the enrollee needs this for mobility.The Plan denied your request. The Plan says the documentation does not show that criteria for power mobility assistance are met.The Plan must follow Medicare rules. Medicare rules say that power mobility devices ordered by podiatrists are statutorily non-covered.Therefore, we decided that the Plan does not have to pre-approvea power scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 18, 2019.You asked the Plan to pay for the ambulance services. You say that after treatment you declined going to the hospital because all your readings and body functions were back to normal.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 April 18, 2019. 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 April 18, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member is not at baseline and that the Physical Therapist and Occupational Therapist both recommend that the patient be admitted for Skilled Nursing Facility Care. The Plan denied your request. The Plan says that the member does not require the skilled therapy or nursing services required for a skilled nursing facility stay.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 5, 2019 to June 20, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have skilled nursing or skilled rehabilitation needs nor did he receive skilled therapy only available at a skilled nursing facility.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 pay for the skilled nursing services from June 5, 2019 to June 20, 2019. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from June 5, 2019 to June 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forgenetic testing services provided to the enrollee on April 29, 2019.You asked the Planto pay forgenetic testing services. You say that the services were medically necessary.The Plandenied your request. The Plansaysthe enrollee did not meet criteria for these services.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 pay for genetic testing services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have metastatic pancreatic cancer. Testing related to pancreatic cancer, and for which there are associated treatments, would be considered medically necessary and reasonable. Testing unrelated to pancreatic cancer, and/or for which there are no associated treatments, is not considered medically necessary or reasonable. The panel testing provided, which was inclusive of tests unrelated to pancreatic cancer and/or for which there are no associated treatments, was not medically necessary or reasonable.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing services have not been met.Therefore, we decided that the Plandoes not haveto pay forgenetic testing services provided to the enrollee on April 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig
You asked the Plan to pre-approve Aimovig. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 pre-approve Aimovig
Benefits for Aimovig may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (80307, G0483) provided April 3, 2019.
You asked the Plan to pay for drug testing services. You say that these services were medically necessary. The Plan denied your request. The Plan says an incorrect place of service was billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the billed services are not supported in the medical record. Specifically, the services were billed with a place of service of 81- Laboratory. The record indicates that the lab specimen was not obtained in the laboratory. The place of service should be the location where the specimen was obtained. Based on this information, we decided that Medicare rules for coverage of drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, G0483) provided April 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe vascular surgery services to be provided by an out of network (OON) interventional radiologist.You asked the Planto pre-approvethe OON vascular surgery services. You say that it is felt that the enrollee needs to be approved to receive this care from this provider.The Plandenied your request. The Plansaysthe enrollee's network has vascular surgery providers able to render this care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvethe vascular surgery services to be provided by an out of network (OON) interventional radiologist
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says that rules for coverage have not been met.
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 the MRI. Our reviewer says that the MRI is medically necessary. Our physician reviewer found in this case, there is documentation of subjective complaints of increased back pain and radiculopathy with neurologic findings on physical exam. There is specific indication for an MRI of the lumbar spine. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
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-approvezoledronic acid (J3489).You asked the Plan to pre-approvezoledronic acid (J3489). You say that the requested zoledronic acid is medically necessary.The Plan deniedyour request. The Plan says the requested zoledronic acid is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 zoledronic acid (J3489). Our reviewer says that the requested zoledronic acid is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is noted to be a post-menopausal female, who takes chronic steroids and is shown to have osteoporosis via a DEXA scan. The enrollee does take calcium and a multivitamin. A request has been made for Reclast to treat her condition. There is no indication that the enrollee has tried any other form of osteoporosis medication, that the enrollee is allergic or intolerant to such medications, or that such medications were ineffective. Therefore, the request for Reclast as an apparent first-line agent to treat the enrollee's osteoporosis is not shown to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of zoledronic acid (J3489) have not been met.Therefore, we decided that the Plan does not have to pre-approvezoledronic acid (J3489)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron 8mg tablets.You asked the Plan to pre-approve the ondansetron tablets. You say that this is necessary to treat and prevent nausea associated with chemotherapy.The Plan denied your request. The Plan says this is not covered by Medicare Part B in this circumstance.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 pre-approve ondansetron 8mg tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs and parts.
You asked the Plan to pre-approve the wheelchair repairs and parts. The Plan denied your request. The Plan says the requested repairs are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that, in order for coverage to be considered, information must be submitted to confirm that Medicare criteria for coverage have been met. We looked at the file and Medicare rules. The case file did not include any medical records to support medical necessity. The only medical documentation provided was a request for the parts with their prices. The case file shows that the Plan made reasonable attempts to obtain medical records. Based on this information, we decided that Medicare rules for coverage of the wheelchair repairs and parts have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs and parts.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio for the enrollee.You asked the Plan to pre-approve Zarxio. The Plan denied your request. The Plan says that use of this medication for the enrollee's disease has not been shown to be beneficial.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 Zarxio. Our reviewer says that Zarxio is not medically reasonable and necessary for the enrollee in this case. Zarxio is not FDA-approved for the enrollee's diagnosis. The use of this drug is not listed as indicated, supported or recommended in any of the compendia for the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Zarxio.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met.Therefore, we decided that the Plan does not have to pre-approve Zarxio for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone graft (D7953) tissue regeneration (D4266) and limited oral evaluation (D0140) provided October 1, 2019.You asked the Plan to pay forthe dental services. You say that you feel that the services were medically necessary and should be covered by the plan.The Plan denied your request. The Plan says the requested services are not covered under the plan 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 forbone graft (D7953) tissue regeneration (D4266) and limited oral evaluation (D0140) provided October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator.
You asked the Plan to pre-approve a hypoglossal nerve stimulator. Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCA A57642 provides a list of non-covered services due to the services being investigational/experimental. We looked at the file and Medicare rules. Per A57642, the requested hypoglossal nerve stimulator is considered to be an investigational/experimental procedure, and therefore is non-covered. Based on this information, we decided that Medicare rules for coverage of a hypoglossal nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit provided on October 22, 2019.You asked the Plan to pay forthe outpatient office visit. You say that on the October 22, 2019 date of service this enrollee was not covered under hospice.The Plan denied your request. The Plan says Original Medicare would be responsible for payment ofall Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on October 20, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe outpatient office visit provided on October 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 11, 2019 to October 10, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says there was no daily skilled nursing or therapist need.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from September 11, 2019 to October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) provided September 2, 2019.
You asked the Plan to pay for initial observation care. You say that these services were related to an emergency. The Plan denied your request. The Plan says these services were not authorized and not provided in the emergency room.
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 initial observation care (99220) provided September 2, 2019.