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

We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) for teeth #7, #8, #14 and #15.

You asked the Plan to pre-approve the crowns. You say that the enrollee has present and recurring decay and pain on these teeth due to grinding. These crowns are necessary. The Plan denied your request. The Plan says teeth #14 and #15 already have crowns and do not show any gaps around the edges or any signs of decay. The documentation also does not show that teeth #7 and #8 are significantly damaged and a simpler restoration may be more appropriate for these teeth instead. Documentation does not show that the requested services are medically necessary in this case.

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 crowns 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 crowns. Our reviewer says that the documentation provided does not support that the requested crowns are medically necessary. Our physician reviewer found that teeth #14 and #15 have previously existing crowns. Tooth #7 is not clearly seen on the panoramic view but appears to have a resin filling placed, and tooth #8 has a relatively small distal restoration. In general, a tooth may require a crown restoration if there is a significant amount of tooth structure missing that requires full coverage to provide strength. Teeth #7 and #8 do not appear to have a significant amount of missing structure, and in this case a more conservative type of restoration would be most appropriate. Teeth #14 and #15 have existing crowns that do not show any marginal breakdown that would indicate recurrent decay, which would be a reason to replace an existing crown. Without documentation that the crowns are no longer serviceable, there is no reason for replacement of these crowns. Given the lack of structural breakdown of teeth #7 and #8 and a lack of clearly exhibited defects of the existing crown restorations on teeth #14 and #15, there is no medical necessity for the requested crowns.

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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) for teeth #7, #8, #14 and #15.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care (Current Procedural Terminology (CPT) code 97610), for the enrollee.

You asked the Plan to pre-approve the ultrasound. You say that you need the requested service because of an ulcer on your foot. The Plan denied your request. The Plan says that your records do not show a medical reason you cannot have conventional debridement.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate was provided the records and has failed to forward them to support the decision to deny based on medical criteria not being met. Therefore, we decided that the Plan has to pre-approve low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care (Current Procedural Terminology (CPT) code 97610), for the enrollee.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transportation services provided on March 16, 2021.

You asked the Plan to waive the copayment for transportation services. You say that you could have driven yourself so you do not think you should pay for the transportation services. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $315 copayment for Ambulance Services.

You have been asked to pay $315 copayment for transportation services. Transportation services fall within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for transportation services provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom Continuous Glucose Monitor (CGM).

You asked the Plan to pre-approve the Dexcom CGM. You say that you have tried another CGM before and it didn't work for you. You say that the Dexcom system will help you get your A1C down. You say that the documentation of your lab tests supports your need for the item being requested. The Plan denied your request. The Plan says the criteria for coverage cannot be identified as met and the requested CGM is non-covered.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The case file shows that the Plan made reasonable attempts to obtain supporting documentation and clarification from your primary care physician (PCP). However, no medical records were provided by your PCP. The documentation you provided does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, or has had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the Dexcom CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital
inpatients or outpatients, the inpatient or outpatient hospital POS code would be reported regardless of where
the face-to-face service takes place.
We looked at the file and Medicare rules. In this case, the services were billed with POS 15 (mobile unit).
However, the enrollee was an inpatient at the time the services in question were provided. This means that the
inpatient POS code must be billed.
Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for the services provided on February 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 1, 2021, to January 12, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you pay a lot for your Plan and feel that they should cover these charges as they are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $0 copayment for days 1-20 and a $178 copayment for days 21-100 for SNF care. The record shows that you had a SNF stay from December 14, 2020, to January 12, 2021. You are not being
charged a copayment for days 1-20 (December 14, 2020, to January 2, 2021). You are responsible to pay a $178 copayment for days 21-29 (January 3, 2021, to January 11, 2021). The total amount you owe is: $178 (copayment) x 9 (SNF days) = $1,602. You have been asked to pay the total copayment amount of $1,602 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from January 1, 2021, to January 12, 2021.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 you are receiving appropriate care at the present acute care hospital and you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an LTACH is not medically
necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for enteral nutrition.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in-network.

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 Plan does not have to pre-approve an out-of-network referral for enteral nutrition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) provided April 15, 2021.

You asked the Plan to pay for the comprehensive periodontal exam. You say that you don't understand how you can have your teeth cleaned without an evaluation of your gums. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) provided April 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance for a spinal injection (77003) provided December 17, 2020.

You asked the Plan to pay for the fluoroscopic guidance for a spinal injection. You say that you would like this claim reprocessed based on the medical necessity. The Plan denied your request. The Plan says the claim is missing the required primary code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules also say that an add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. 

We looked at the file and Medicare rules. In this case, we have confirmed that code the fluoroscopic guidance is an add-on code and cannot be paid as billed as it was not billed with a required primary code. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance for a spinal injection have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance for a spinal injection (77003) provided December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 19, 2021.

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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto, 20 mg tablet.

You asked the Plan to pre-approve Xarelto. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto, 20 mg tablet.

Benefits for Xarelto 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not reflect that you are currently insulin-treated with three or more daily injections

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. 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 radiofrequency ablation 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 radiofrequency ablation. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain. In 2017 the enrollee underwent diagnostic medial branch blocks which did not afford the enrollee relief. On March 4, 2021 the enrollee underwent C2-C5 diagnostic medial branch blocks and achieved 50% pain relief. On March 25, 2021 the enrollee again underwent diagnostic medial branch blocks and achieved 50% pain relief. The standard of care for positive block is 80% pain relief. This was not achieved and therefore, the request is considered not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from March 2, 2021, through
March 30, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says SNF services are not
medically necessary.
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 pay for SNF services. Our reviewer says that daily
skilled services are not medically necessary. Our physician reviewer found that at the time of admission into
the nursing facility the enrollee was medically stable without any skilled nursing needs. The enrollee did not
require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of care. She was not
expected to make measurable gains within a reasonable and predictable period of time or require skilled
therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not
require any skilled services on an inpatient basis, at a SNF level of care. The enrollee did not have any parental
medications, complex wound care or nutrition given via a feeding tube. She was medically stable without any
acute exacerbations of chronic medical problems. Her physical function was at or near her baseline and she
could have received further services at a lower level of care. Admission to the nursing facility at a skilled level
of care for inpatient skilled services was not medically necessary. During the period in question, the enrollee
required custodial services. The skilled services were not medically necessary.
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 pay for SNF services provided from March 2, 2021, through March 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement ultralightweight wheelchair.

You asked the Plan to pre-approve a replacement ultralightweight wheelchair. You say that your chair is falling apart, and the supplier refuses to fix it. The Plan denied your request. The Plan says your wheelchair was provided new in December 2020 and can be repaired.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have ultralightweight wheelchair. This ultralightweight wheelchair serves the same purpose as a replacement ultralightweight wheelchair. Your current wheelchair is still under reasonable Useful lifetime. Therefore, we decided that the Plan does not have to pre-approve a replacement ultralightweight wheelchair.