Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 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 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services. The medical records provided show the enrollee does require skilled therapy services. Therapy notes indicate treatment 3-4 times per week is recommended. This enrollee does not require the services on an inpatient basis, only 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), and the bitewings - four radiographic images (D0274) received March 2, 2021.

You asked the Plan to pay an additional amount for the periodic oral evaluation, and the bitewing x-rays. You say that you have a $1,000 benefit limit towards in-network and out-of-network services, and therefore your bill should have been paid in full. The Plan denied your request. The Plan says if you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment.

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 only covered under this benefit up to the Plan's Maximum Allowable Charge (MAC) when received out-of-network. The Plan agreed to cover the requested services up to 100% of the MAC. If you receive services out-of-network you might be billed for charges above what the plan pays, even for services listed as $0 copayment. The Plan has provided coverage in accordance with the contract. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), and the bitewings - four radiographic images (D0274) received March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retrograde filling - per root (D3430), the apicoectomy - anterior (D3410), and the incisional biopsy of oral tissue-soft (D7286) received February 1, 2021.
You asked the Plan to pay for the retrograde filling, the apicoectomy, and the incisional biopsy. You say that these services were necessary because you had a gum infection. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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 retrograde filling - per root (D3430), the apicoectomy - anterior (D3410), and the incisional biopsy of oral tissue-soft (D7286) received February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee cannot tolerate standing or walking more than a few minutes due to pain and leg numbness and weakness. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.

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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices are experimental. More research is needed to show safety and efficacy of the devices. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that the requested power mobility device (K0800) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power mobility device (K0800).
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power mobility device. Our reviewer says that the enrollee does not meet criteria for the requested power mobility device (K0800). Our physician reviewer found the documentation indicates that the enrollee has a mobility limitation, but it is not clear what mobility related activities of daily living are significantly impaired in the home. The documentation does not reveal that the enrollee's mobility limitation cannot be sufficiently and safely resolved by the use of an
appropriately fitted manual wheelchair. The documentation does not reveal that the enrollee's home provides adequate access for the requested wheelchair and that the use of the wheelchair will significantly improve the enrollee's mobility-related activities of daily living. 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 power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on September 15, 2020, by an out of network (OON) provider.
You asked the Plan to pay for a drug test. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a drug test (G0483) provided on September 15, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that you were not evaluated adequately. The Plan denied your request. The Plan says the evaluation shows you can ambulate in the home and in the community.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you are able to ambulate, and your condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs provided on January 11, 2020.

You asked the Plan to pay for the drugs. You say that The Plan denied your request. The Plan says drugs provided out of the country are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that the provider or beneficiary, as appropriate 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 medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan does not have to pay for drugs provided on January 11, 2020.
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 in the Medicare rules section. 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 the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral periapical radiographic images (D0220, D0230) provided on November 5, 2020.
You asked the Plan to pay for a limited oral evaluation, and intraoral periapical radiographic images. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue 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 a limited oral evaluation (D0140), and intraoral periapical radiographic images (D0220, D0230) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had to an outpatient hospital clinic on October 5, 2020.

You asked the Plan to waive the copayment for the outpatient hospital clinic services. You say that you believe you are being overcharged for this visit. The Plan denied your request. The Plan says you were charged this amount correctly. The Plan says that because the allowed amount for this service ($114.20) is less than your copayment obligation, you are responsible for the full allowed amount.

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 $295 copayment for services in an outpatient hospital facility.

You have been asked to pay a $295 copayment for the outpatient hospital clinic services. 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 visit you had to an outpatient hospital clinic on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on December 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the hearing aids. You say that these hearing aids are necessary, and you do not understand why the enrollee is limited to in-network providers. The Plan denied your request. The Plan says these hearing aids were purchased out-of-network, and the Plan only covers out-of-network services in limited circumstances. The Plan does not have a record that shows that you, the enrollee, or the provider called at any point to verify benefits or eligibility prior to services.
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 hearing aids provided on December 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator (E0466).
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says your needs can be met with a BiPAP.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested home ventilator is not medically necessary. Our physician reviewer found there are no pulmonary function tests included in the submitted records, so there appears to be uncertainty about your diagnosis of COPD. There also are no arterial blood gas results. There is no documented failure of BiPAP. Medicare does not cover a ventilator when used as BiPAP.
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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a ventilator (E0466).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status,
respiratory failure, and aspiration pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.
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 this device. Our reviewer says that the requested items and services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), periapical first radiographic image (D0220), panoramic radiographic image (D0330), bitewing - single radiographic image (D0270), resin-based composite - four or more surfaces, posterior (D2394), application of desensitizing medicament (D9910) provided February 5, 2021.

You asked the Plan to pay for the oral exam periapical x-ray, panoramic x-ray, bitewing x-ray, resin-based composite, and application of desensitizing medicament. You say that you were not aware the provider had opted out of Medicare and the services should be covered. The Plan denied your request. The Plan says since the provider who rendered the services has opted out of Medicare, the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. 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. 

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the oral exam periapical x-ray, panoramic x-ray, bitewing x-ray, resin-based composite and application of desensitizing medicament have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), periapical first radiographic image (D0220), panoramic radiographic image (D0330), bitewing - single radiographic image (D0270), resin-based composite - four or more surfaces, posterior (D2394), application of desensitizing medicament (D9910) provided February 5, 2021.