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

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided June 23, 2020.
You asked the Plan to pay for the dental service. You say that the surgical extraction was needed due to an accidental fall. You also say that the service should be covered. The Plan denied your request. The Plan says the surgical extraction is considered dental in nature. The Plan also says the surgical extraction is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided June 23, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the abdomen without contrast (74181).
You asked the Plan to pre-approve the MRI of the abdomen. You say that an MRI of the abdomen is medically necessary for the enrollee. The Plan denied your request. The Plan says that an MRI of the abdomen is not medically necessary.
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 of the abdomen. Our reviewer says that an MRI of the abdomen is medically necessary. Our physician reviewer found that an MRI of the abdomen was requested as the patient has biliary tract disease with the inability to have a full colonoscopy secondary to a hernia, and unexplained ascites. The information gleaned from these tests will be helpful in the diagnosis of a yet undiagnosed condition. The test is both reasonable and indicated. 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 of the abdomen have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the abdomen without contrast (74181).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays (D0210) provided on July 13, 2020.You asked the Plan to pay forthe dental service. You say that you were not aware that the x-rays would not be covered. You say that you confirmed with your dentist that you did receive the bitewing portion required. You also say that this is a hardship for you.The Plan denied your request. The Plan says the complete series of x-rays is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.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 forthe complete series of intraoral x-rays (D0210) provided on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atovaquone-Proguanil HCL.
You asked the Plan to pre-approve the Atovaquone-Proguanil HCL. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's condition 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 Atovaquone-Proguanil HCL.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-ray provided on July 14, 2020.
You asked the Plan to pay for the additional periapical x-ray. You say that you have not previously been to the dentist. You say that the x-rays and exam are covered benefits. The Plan denied your request. The Plan says you have exceeded the limit on this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one intraoral x-ray (periapical or occlusal) per calendar year. The Plan paid for one periapical x-ray provided on July 14, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe resin-based composite provided on August3, 2020.You asked the Plan to pay more forthe resin-based composite. You say that you have a $200 dental allowance for fillings. You say that you want to know why the claim only paid $113.The Plan denied your request. The Plan says the claim processed correctly.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, you also have an annual allowance of $200 for comprehensive dental services. The Plan paid $87 toward the periodontal maintenance provided on January 27, 2020 and $113 toward the resin-based composite provided on August 3, 2020,which exhausted your benefit.Therefore, we decided that the Plan does not have to pay more forthe resin-based composite provided on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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. Ourphysician reviewer found that the patient was admitted to the current acute care facility with septic shock, bacteremia, acute kidney injury, and acute hypoxic respiratory failure. She was treated with pressors, mechanical ventilation, hemodialysis, woundcare to left foot, and antibiotics. She recently was able to tolerate trach collar, discontinue dialysis, discontinue pressor support, but continues to have low grade fever and leukocytosis as well as requires a rectal tube and ongoing nasogastric tube feeds. The patient appears to be gradually improving overall, but requires an additional short term stay in the acute care hospital (less than 25 days) to stabilize, which can be safely completed at the current facility. The patient does not require servicesat the LTACH that are not already available at the current facility.There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered when treatment has completed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forinpatient mental health care provided from June 6, 2020, to June 9, 2020.You asked the Plan to waive the deductible forinpatient mental health care. You say that the enrollee should owe a $0 copayment.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan says that there is a $750 deductible for inpatient mental health care. The enrollee received inpatient mental health care from June 6, 2020, to June 9, 2020. The record shows that they had paid $0 toward the $750 deductible. Therefore, the enrollee is responsible to pay the total allowed amount of $548.40. The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for inpatient mental health care. This cost sharing is a contractual obligation that had not been met at the time inpatient mental health care was received on June 6, 2020 to June 9, 2020.Therefore, we decided that the Plan does not have to waive the deductible forinpatient mental health care provided from June 6, 2020, to June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the City on March 
14, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 March 14, 2020. 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 by the City
on March 14, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forambulance transportation provided on January 17, 2020.You asked the Plan to pay forambulance transport. You say that you did not receive this service.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because there were no indications that non-emergent transportation needed to be provided.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport. Our reviewer says that this transportation meets the Medicare criteria for coverage. Our physician reviewer found you were at very high risk of fall and very high risk of fracture after falling. Ambulance transportation was indicated as there was a high likelihood of more severe injury that would have precluded other means of transportation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transport have been met.Therefore, we decided that the Plan has to pay forambulance transportation provided on January 17, 2020.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee is medically stable and does not require daily skilled nursing or skilled rehabilitation services.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-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe nuclear medicine outpatient hospital services provided May 1, 2020, to May 15, 2020.You asked the Plan to waive the coinsurance forthe outpatient hospital services. You say that there was an error in the medical codes submitted.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 20% coinsurance for nuclear medicine services. You have been asked to pay a 20%coinsurance for the outpatient hospital services. These services fall within the nuclear medicine 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 coinsurance forthe nuclear medicine outpatient hospital services provided May 1, 2020, to May 15, 2020.Your complaint about a possible error regarding billing codes 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Powered Upper Extremity Range of Motion Assist Device (L8702).
You asked the Plan to pre-approve the motion assist device. You say that the device is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the motion assist device. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has reduced upper extremity functionality and would benefit from the robotic assist device. This device has the potential for a substantial improvement in quality of life of the patient. 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 motion assist device have been met. Therefore, we decided that the Plan has to pre-approve a Powered Upper Extremity Range of Motion Assist Device (L8702).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not haveto provide a PET scan.You asked the Plan to provide a PET scan. You say that you need a PET scan. The Plan denied your request. The Plan says your doctor has not ordered a PET scan for you.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered if medically necessary and reasonable. This is not a service that can be done without a doctor's order. Therefore, we decided that the Plan does not have to provide a PET scan.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to provide a PET scan.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetranscranial magnetic stimulation.You asked the Plan to pre-approvethe requested services. You say that therapy has not worked.The Plan denied your request. The Plan says you are able to function adequately in the community.The Plan must follow Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered under certain medical indications.We looked at the file and Medicare rules.In this case, there are insufficient medical records showing that you have severe major depressive disorder, that you have demonstrated resistance to treatment with psychopharmacologic agents, andthat you have had a trial of an evidence-based psychotherapy.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvetranscranial magnetic stimulation
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateralknee osteoarthritis. Plain film imaging reports no bony arthritis, but deceased in space over the medical joint with normal bone density. There is no meniscal tearing or evidence of chondral thinning on magnetic resonance imaging (MRI). There is no documentation of specific conservative care. The records do not support that Orthovisc is reasonable or medically necessary at this time.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-approveOrthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulse oximeter.
You asked the Plan to pre-approve a pulse oximeter. You say that that your physician recommends this device
for you. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that oximeters will be denied as non-covered because
they are monitoring devices that provide information to physicians to assist in managing the beneficiary's
treatment. Therefore, we decided that the Plan does not have to pre-approve a pulse oximeter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on January 31, 2020.
You asked the Plan to pay for the physician service. You say that the claim was billed correctly. You say that the enrollee was not enrolled in hospice at the time the services were rendered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician telephone patient service (99443) provided on
June 18, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the physician telephone patient service. You say that the services provided were
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the
facility or the provider; therefore, payment has been correctly denied.
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 the physician telephone patient service (99443)
provided on June 18, 2020, by an out of network (OON) provider.