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

We decided that the Plan does not have to pay forthe cone beam CTcapture with interpretation (D0364) and the retreatment of a previous root canal (D3348) provided on September 10, 2020.You asked the Plan to pay forthe dental services. You say that you were advised when you signed up for the plan that root canals were covered at 50%. You say that it does not make sense that the filling would be covered but not the root canal.The Plan denied your request. The Plan says the cone beam CT capture with interpretation is not listed as a covered service. The Plan says that retreatment of a previous root canal is not listed as a covered service either. The Plan also says that any services not listed are 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. Additionally, the record shows that the plan representative advised that endodontics and oral surgery work are covered, and that there was no mention of a need for a retreatment of a previous root canal.Therefore, we decided that the Plan does not have to pay forthe cone beam CT capture with interpretation (D0364) and the retreatment of a previous root canal (D3348) provided on September 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Evenity 210mg syringes.
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your
request. The Plan says that you must be using this drug for a medical issue that is approved by the U.S. Food
and Drug Administration (FDA).
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that Evenity
is medically necessary. Our physician reviewer found Romosozumab (Evenity) is a medication used to treat
osteoporosis. It has been found to decrease the risk of fractures of the spine. Research shows the drug increases
bone formation and decreases bone resorption in postmenopausal women with low bone density.
Romosozumab was approved for medical use in Japan, the United States, and the European Union in 2019. The
U.S. Food and Drug Administration (FDA) considers it to be a first-in-class medication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have been met. Therefore, we decided that the Plan has to pre-approve
Evenity 210mg syringes.
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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the physical therapy visit provided on October 13, 
2020. We decided that the Plan does not have to waive the copayments for the physical therapy visits provided 
on September 2, 2020, September 8, 2020, September 11, 2020, and September 18, 2020.  
 
You asked the Plan to waive the copayments for physical therapy. You say that you already had five visits and 
will have seven more. You say that it is difficult to pay your copayment for every visit. The Plan says that the 
copayments applied correctly. 
 
We decided that the Plan has to reduce the copayment for the physical therapy visit provided on October 
13, 2020.  
 
The Plan contract says that enrollees must pay $40 for each Medicare-covered physical therapy visit. The claim 
line item shows that you were charged a $45 copayment for the visit provided on October 13, 2020. Therefore, 
we decided that the Plan has to reduce the copayment for the physical therapy visit provided on October 13, 
2020, from $45 to $40. 
  
We also decided that the Plan does not have to waive the copayments for the physical therapy visits 
provided on September 2, 2020, September 8, 2020, September 11, 2020, and September 18, 2020. 
 
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 $40 for 
each Medicare-covered physical therapy visit. Therefore, we decided that the Plan does not have to waive the 
$40 copayment for each physical therapy visit provided on September 2, 2020, September 8, 2020, September 
11, 2020, and September 18, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 8, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plandid not pre-approve the laboratory services. 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 laboratory services provided on October 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSkilled Nursing Facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the services are medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of 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 not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. 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-approveSkilled Nursing Facility (SNF) services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 1, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says cardiovascular assay testing is not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. Cardiovascular
assay testing is not covered. Therefore, we decided that the Plan does not have to pay for lab services provided
to the enrollee on May 1, 2020
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies (A9270) provided on July 3, 2020. 
 
You asked the Plan to pay for ambulance supplies. You say that since this was a 911 call the provided services 
are Medicare-covered services. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
Medicare rules say that ambulance supplies are all considered part of the general ambulance service and 
payment for them is included in the payment rate for the transport. The Plan follows the same rules. 
 
We looked at the case file and Medicare rules. Ambulance supplies are paid for as part of the general 
ambulance service. Based on this information, we decided that Medicare rules for coverage of ambulance 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for ambulance supplies 
(A9270) provided on July 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 30, 2020.
You asked the Plan to pay for the ambulance services. You say that your doctor called for this service. 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 September 30, 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 on September 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs skilled nursing care and inpatient therapy. You say that the enrollee needs to be in a rehab facility and not doing it at home. You say that the records provided support the need for care in an IRF.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 above.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 therequested 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 does not require an acute hospital inpatient staywith an interdisciplinary approach to rehabilitation care. The enrollee is experiencing confusion and fatigue while living at home after a hospitalization in November 2020 for altered mental status and urinary tract infection. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the 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 ofIRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on July 24, 2020, by an out-of-
network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
there are in-network providers available for these 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 chiropractic services provided on July 24, 2020,
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the inpatient care you received from July 26, 2020, to July 28, 2020.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.

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 $300 copayment for per day for days 1-5 per hospital stay. 

Review of the file shows that you were provided two days of inpatient care from July 26, 2020, to July 28, 2020. You have been asked to pay a $300 copayment per day for inpatient care, totaling $600. The services fall within the inpatient hospital 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 inpatient care you received from July 26, 2020, to July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided June 16, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support the services at issue.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, 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 plan made multiple requests for medical records. No medical records were provided. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided June 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another setting, such as an acute
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.
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 the enrollee is currently undergoing treatment at an ACH for pneumonia. The
enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care needs.
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-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator
electrode array, epidural (63650) and implantable neurostimulator electrode (L8680) for the enrollee.
You asked the Plan to pre-approve these services. You say that this is the best treatment and should be covered.
The Plan denied your request. The Plan says that the documentation does support that pain medications are
providing good overall reduction in pain and improvement in functional ability.
The Plan must follow Medicare rules. Medicare rules say that dorsal column stimulators are covered if the
above criteria have been met.
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. There is no
documentation that all treatments have been exhausted. More treatment is needed. More evaluation is needed.
The stimulator should be the last resort after all treatments have failed. 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 the percutaneous implantation of neurostimulator electrode array, epidural (63650) and
implantable neurostimulator electrode (L8680) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered as the height adjustment feature is a convenience feature.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) provided August 1, 2020.
You asked the Plan to pay for the orthosis. You say that you have attached the doctor's orders along with the clinical notes. The Plan denied your request. The Plan says the records provided do not support the billed service.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number and the proof of delivery ticket did not include an order number or details to corroborate the delivery ticket submitted, nor is it itemized to indicate the specific supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) provided August 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNULOJIX 250mg vial (J0485) for the enrollee.

You asked the Planto pre-approv ethe drug. You say that therapy must be continued as you are a COVID-19 risk.The Plan denied your request. The Plan says the FDA has a black box warning for NULOJIX.

The Plan must follow Medicare rules. The rules say that certain drugs must be provided in facilities equipped and staffed with adequate laboratory and supportive medical resources, rather than the home setting.

The requested drug is to be provided in the home setting. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plan does not have to pre-approveNULOJIX 250mg vial (J0485) for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approveLTACH services.