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

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth #3 and 14.

You asked the Plan to pre-approve the core build up. You say that the services were done incorrectly. You say that you need them to be redone. You also say that you are upset that you have been getting the services for the same tooth multiple times from this provider.The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says if a dental item or service is not listed in the benefit chart then it is not covered.

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 pre-approve core build up (D2950) for teeth #3 and 14.

Your complaint about getting services for the same tooth multiple times from the same provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services (V5261) provided on July 15, 2020.
You asked the Plan to pay for the hearing aid services. You say that you feel hearing aids are important to maintaining your quality of life. The Plan denied your request. The Plan says they do not cover the purchase of hearing aids.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aid services may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aid services (V5261) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions-upper left quadrant (D7311).

You asked the Plan to pre-approve alveoloplastyin conjunction with extractions. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not a covered 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. Only services listed in the Plan's dental member hand book are covered.

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. Specifically, the service at issue is not listed in the Plan's dental member handbook, and therefore, is not a covered benefit.Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions-upper left quadrant (D7311)
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that that you are functioning at a home care level and do not require daily
skilled therapy to restore or maintain function.
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 care. Our reviewer says that SNF
care is medically necessary and reasonable in this case. You do not have documented skilled nursing needs.
You do have documented skilled therapy needs. You are functioning below your baseline and have not yet
been shown to have reached a plateau in function. Daily skilled services are required to establish a maintenance
program and/or to prevent deterioration of your condition. Your care needs at this point, as a practical matter,
cannot be provided at a lower level of care. Our physician reviewer found that your condition meets Medicare
criteria for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET/CT scan of the body, head to thigh.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there were no unclear results of standard imaging received.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the requested imaging is medically reasonable and necessary. Our physician reviewer found you have two very different and separate thoracic malignancies - squamous cell cancer and malignant plasmacytoma. The plasmacytoma is a tumor which may be associated with Multiple Myeloma and close surveillance is required despite a negative bone marrow biopsy. CMS has approved PET/CT for up to 3 scans for squamous cell cancer adding a further justification for such a scan considering the second cancer, squamous cell carcinoma of the lung. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve PET/CT scan of the body, head to thigh.
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: Inpatient Hospital
Decision: Favorable

We decided that the Planhasto pay forinpatient admission for surgery for the enrollee.You asked the Planto pay foracute inpatient hospital care. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis can be done in ambulatory or outpatient status.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 rulesto determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrolleerecently underwent a BKA, which is showing signs of infection and mild wound dehiscence. Hospitalization is planned to debride the wound, apply a wound vac, provide ongoing wound care and provide IV antibiotics. The totality of this care is expected to last 4-5 days. As such, the documentation supports a reasonable belief that more than two midnights of medically necessary care is expected. Hospitalization at the inpatient level of care is appropriate.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 been met.Therefore, we decided that the Planhas to pay forinpatient admission for surgery for the enrollee.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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-approvea core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildup. The Plan denied your request. The Plan says this service is not covered.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 pre-approvea core buildup, including any pins when required (D2950).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forOphthalmological services; medical examination and evaluation with initiation or continuation of diagnostic and treatment program (92014) provided on May 28, 2020.You asked the Plan to pay foreye exam. You say that the member's hospice expired on the date of service.The Plan denied your request. The Plan says Original Medicare is responsible for payment until the start of the next month after hospice revocation or expiration.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 May 28, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forOphthalmological services; medical examination and evaluation with initiation or continuation of diagnostic and treatment program (92014) provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing provided on July 8, 2020.
You asked the Plan to pay for the GeneSight testing. You say that you would like the plan to reconsider their
denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by
licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for
patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe
depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication failure.
We looked at the file and Medicare rules. Review of the file shows that this testing was ordered by an internal
medicine doctor and not a licensed psychiatrist or neuropsychiatrist. Based on this information, we decided that
Medicare rules for coverage of the GeneSight testing have not been met. Therefore, we decided that the Plan
does not have to pay for the GeneSight testing provided on July 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided
from August 30, 2020, to September 1, 2020.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that the tests were
necessary. 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 $225
copayment for advanced imaging.
You have been asked to pay a $225 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging 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 myocardial perfusion imaging provided from August 30,
2020, to September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxychloroquine tablets 200mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Hydroxychloroquine tablets 200mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthodontics fixed pontic for bridge (D6245), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve prosthodontics fixed pontic custom fabricated abutment, and abutment supported porcelain/ceramic crown. You say that the services requested are medically necessary. The Plan denied your request. The Plan says the medical records do not support the need for the pontic bridge, and the abutment crown and custom abutment are not covered services.
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 prosthodontics fixed pontic for bridge when 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 prosthodontics fixed pontic for bridge. Our reviewer says that the requested pontic for a bridge is not medically necessary. Our physician reviewer found the basic claim that the member cannot not tolerate impressions while undergoing implant treatment is insufficient to support the claim that there was a physical or neurological disorder that preclude placement of a removable prosthesis. 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 prosthodontics fixed, pontic for bridge have not been met. Furthermore, though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment and abutment supported porcelain/ceramic crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve prosthodontics fixed pontic for bridge (D6245), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe precision attachment (D5862), overdenture (D5865), and bone replacement graft for ridge preservation (D7953).You asked the Plan to pre-approvethe precision attachment, overdenture, and bonereplacement graft for ridge preservation. You say that these services are medically necessary for your current condition.The Plan denied your request. The Plan says this service is not covered under your benefit package.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 pre-approvethe precision attachment (D5862), overdenture (D5865), and bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2, Motion G Orthotic Device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that given that traditional rehab for her right
dominant arm and less sophisticated medical devices have been tried and failed, her provider has referred her
for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered
experimental and investigational. There is insufficient evidence of its safety and effectiveness and it is not
standard medical practice
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to preapprove
MyoPro 2, Motion G Orthotic Device (L8702).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.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 services. Our reviewer says that daily skilled services are notmedicallynecessary. Our physician reviewer found that based on the documentation provided, the enrollee does not have documented skilled nursing needs.The enrollee does not have documented skilled therapy needs.Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. HHS, AL, LTC).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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99214) provided on February 13, 2020.
You asked the Plan to pay for an office visit. You say that this service was medically necessary and payable. The Plan denied your request. The Plan says that this provider is not eligible for payment because it was billed with an incorrect taxonomy code.
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. The reported NPI shows that the billing provider is eligible to bill for their services. Though the Plan states that the provider billed with an incorrect taxonomy, the Plan has not provided a rule that would indicate that this is not payable. Therefore, we decided that the Plan has to pay for an office visit (99214) provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor and receiver for a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a non-therapeutic CGM and supplies are not covered. We looked at the file and Medicare rules. The requested services are for a non-therapeutic CGM. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sensor and receiver for a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary.The Plan denied your request. The Plan says that this service is considered experimental and investigational.

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 these services.Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer is experimental. More research is needed to show safety and efficacy. There is no spinal instability. Hardware is not needed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the ambulance transport provided.

You asked the Plan to waive the co payment for the ambulance transport. You say that you just started retirement and are unable to pay the bill.The Plan denied your request. The Plan says the co payment 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 $200 co payment for each one-way Medicare-covered ground ambulance trip.

You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls 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 co payment for the ambulance transport provided.