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

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 30, 2020.
You asked the Plan to pay for the dental service. You say that you were unable to schedule your 2 cleaning services within 6 months from each other. You say that your May 2020 visit was rescheduled for July. You say that instead of waiting until January 2021, you took the only opening the office had on November 30, 2020. You also say that you did not want to use your second cleaning service. The Plan denied your request. The Plan says prophylaxis is covered once every 6 months. The Plan also says that the frequency limit has been exceeded.
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 and prophylaxis, the frequency limit has been exceeded. The record shows that the Plan paid for the prophylaxis that you received on July 13, 2020, less than 6 months prior. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two prosthesis components defined by (L5981 and L5986).
You asked the Plan to pre-approve the prosthesis components. You say that the claim should be paid. The Plan denied your request. The Plan says they believed the prosthesis was necessary and overturned that part of the claim, but upheld the denial of codes L5981 and L5986).
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files. 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 prosthesis components. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is not sufficient clinical documentation of functional need for the technologic or design feature requested. There is not sufficient clinical information about the enrollee's history and current condition which supports the designation of the functional level by the practitioner or the prosthetist. Based on the medical records provided there is not sufficient clinical information about the enrollee's history and current condition which supports that he is a K3 ambulator. 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 prosthesis components have not been met. Therefore, we decided that the Plan does not have to pre-approve two prosthesis components defined by (L5981 and L5986).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs from May 29, 2020, to June 6, 2020.
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you are unable to afford this payment. The Plan denied your request. The Plan says you have been asked to pay 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 20% of the cost for Medicare Part B drugs and chemotherapy drugs. You have been asked to pay a total of $315.58 which is 20% of the allowed amount for the Part B drugs. The allowed amount is $1,577.94. ($1,577.94 x 20% = $315.58). The Part B drugs falls within the "Medicare Part B prescription drugs" 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 for Part B drugs provided from May 29, 2020, to June 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home injectable therapy services coded S9542 provided from August 5, 2020 to August 20, 2020.
You asked the Plan to pay for the home injectable therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the rendered services are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S9542 is home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9542 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home injectable therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home injectable therapy services coded S9542 provided from August 5, 2020 to August 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician service. You say that the services provided were medically necessary. You say that the physician provided a statement of medical necessity to justify the reason for the enrollee's stay. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that prior authorization was not obtained before the services were provided. The Plan also says that the services were not urgent or emergent in nature.
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 provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on December 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitoring system (CGM).
You asked the Plan to preapprove the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says you do not meet coverage criteria.
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. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitoring system (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services rendered from February 20, 2019 to December 9, 2019.
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 provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the behavioral health services rendered from February 20, 2019 to December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on October 18, 2020.
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 procedure code 99153 is not separately payable.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on October 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to care for self. The Plan denied your request. The Plan says the enrollee's needs do not require a team of medical professionals to coordinate care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for a decubitus ulcer of the ankle after a recent admission for colitis and gastrointestinal bleeding. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the Vertiflex device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 Entresto for the enrollee. 

Benefits for this drug 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that you need transportation that is fifty-five (55) miles away, it is over the limit of miles. You state you have no other way to get to the appointment and you are going blind which is what the visit is for. The Plan denied your request. The Plan says the requested mileage exceeds what is approved by your supplemental transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Your benefit only allows thirty-six (36) one-way trips whereas each one-way trip must not exceed fifty (50) miles. The health plan contract says, "up to thirty-six (36) one-way trips, combined $0 copayment in and out-of-network, are covered per calendar year (limited to ground transportation only). Each one-way trip must not exceed fifty (50) miles of driving distance." Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 12 and 14, and a pontic (D6245) for tooth # 13.

You asked the Plan to pre-approve the dental services. You say that the bridge is necessary. The Plan denied your request. The Plan says the bridge is not medically necessary. The Plan also says that the bridge will not accomplish much as the enrollee is missing opposing teeth in the lower arch.

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 dental services 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 dental services. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found the provided documentation indicates that a bridge to replace tooth # 13 does not improve the enrollee's masticatory function. Therefore, the reviewer found that the bridge is not medically reasonable or necessary.

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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 12 and 14, and a pontic (D6245) for tooth # 13.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 31, 2020, to
November 2, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says that the services were not medically necessary.
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 rules to
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. Our physician reviewer
found the enrollee presented to the emergency department (ED) with difficulty walking, aphasia, and numbness
in the right foot. He was admitted to the stroke unit and underwent magnetic resonance imaging (MRI). The
records support that, at the time of inpatient admission, the admitting physician reasonably expected that the
enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
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 Plan
has to pay for the acute inpatient hospital care provided from October 31, 2020, to November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve apicoectomy, anterior tooth #8 (CPT code D3410), and retrograde filling, root tooth #8 (D3430).
You asked the Plan to pre-approve the dental services. You say that you are in pain and the services should be covered. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your handbook as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve apicoectomy, anterior tooth #8 (CPT code D3410), and retrograde filling, root tooth #8 (D3430).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 9, 2020.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that procedure code 81455 is denied as not medically necessary. We looked at the file and Medicare rules. The provider billed code 81455. This code is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for revision of right total knee replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and a pleural effusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.