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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 29, 2021.

You asked the Plan to pay for the dental service. You say that you were advised by your specialist you needed to see a dentist to rule out an alternative diagnosis for your facial pain. You also say that you feel this service should be covered. The Plan denied your request. The Plan says limited oral evaluation is covered once per plan year. The Plan also says that the frequency limit has been reached.

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 limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on February 3, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an implant body (D6010 x 3) and the surgical access to an implant body (D6011 x 3) provided on March 26, 2021.

You asked the Plan to pay for the dental services. You say that the plan is lying to you. The Plan denied your request. The Plan says implants are only covered to hold a complete denture. The Plan says that the implants you received are not to hold a complete denture and therefore are not covered. The Plan also says that as a non-covered service, any procedure as a result of an implant placement related to certain oral and systemic conditions or complications is excluded.

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 implant services not related to a complete denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical placement of an implant body (D6010 x 3) and the surgical access to an implant body (D6011 x 3) provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Check Guide test Strips.

You asked the Plan to pre-approve blood glucose test strips. You say that these test strips should be covered. The Plan denied your request. The Plan says there are plan preferred alternatives available.

The Plan must follow Medicare rules. Medicare rules say that only certain providers are covered for diabetic testing supplies unless specific reasons are given as to why an exception is needed. 

We looked at the file and Medicare rules. The documentation does not indicate circumstances why a plan preferred alternative is unacceptable for use. Based on this information, we decided that Medicare rules for coverage of non-plan preferred blood glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Check Guide test Strips.
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. You say that the patient is not at her baseline mobility or activities of daily living status and will benefit from inpatient rehabilitation to restore her prior level of function for safe return home. The Plan denied your request.

The Plan says there are no identified skilled nursing needs, and the member does not need therapy in an inpatient skilled nursing facility level of care. Any further services can be rendered in an outpatient 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at a standby assist to contact guard/minimal assist level with functional mobility including gait to 50 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493).

You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a second set of injections is covered when your prior injection done to find the source of your pain reduced your pain by at least 80%. 

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 injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the records do not show that the previous injection provided at least 80% pain relief. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified periodontal procedure and bone replacement graft provided on May 18, 2021.

You asked the Plan to pay for the unspecified periodontal procedure and bone replacement graft. You say that you are asking for reimbursement for the correct payment amount of $1,065. The Plan denied your request. The Plan says the claim reprocessed to pay for the comprehensive periodontal evaluation, intraoral x-ray, extraction and fluoride treatment. The Plan also says the unspecified periodontal procedure and bone replacement graft are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified periodontal procedure and bone replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified periodontal procedure and bone replacement graft provided on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis (L8702).

You asked the Plan to pre-approve the orthosis. You say that given that traditional therapies have been tried and failed, the enrollee has been referred by his family medicine physician. The Plan denied your request. The Plan says this item is considered experimental and investigational due to the lack of clinical evidence demonstrating an impact on improved health outcomes.

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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 10, 2021.

You asked the Plan to waive the copayment for specialist services. You say that you believe you have already paid for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $15 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a $15 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of chiropractic services.

You asked the Plan to pre-approve the continuation of chiropractic services. You say that the requested continuation of chiropractic services is medically necessary. The Plan denied your request. The Plan says the requested continuation of chiropractic services is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 

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 continuation of chiropractic services. Our reviewer says that the requested continuation of chiropractic services is not medically necessary. Our physician reviewer found the case file does not contain documentation of spinal subluxation shown by x-ray or physical exam. The documentation does not support that further clinical improvement is reasonably expected from ongoing care, as the enrollee's discomfort was the same since her previous chiropractic visit.

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 continuation of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), a crown (D2740), and an unspecified adjunctive procedure (D9999) provided from March 1, 2021, through March 30, 2021.

You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, a crown, and an unspecified adjunctive procedure. You say that you were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, a crown, and an unspecified adjunctive procedure have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), a crown (D2740), and an unspecified adjunctive procedure (D9999) provided from March 1, 2021, through March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on April 15, 2021.

You asked the Plan to pay for a periodic oral evaluation, and a teeth cleaning. You say that you thought the provider was in-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on April 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 12, 2021.

You asked the Plan to pay for the laboratory services. You say that the documents should be reviewed, and the claim processed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services you received on June 4, 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 $270 copayment for ambulance services. 

Review of the files shows that you were provided ambulance services on June 4, 2020. You have been asked to pay a $270 copayment for the services. The services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. If you are being billed for charges beyond any applicable cost-sharing amounts, please contact the Plan directly. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services you received on June 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1830) and the adjustable cane (E0100) rendered by the out-of-network (OON) provider on May 6, 2021.

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal.

The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1830) and the adjustable cane (E0100) rendered by the out-of-network (OON) provider on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve leadless pacemaker insertion.

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 leadless pacemakers are non-covered when furnished outside of a Medicare-approved Coverage with Evidence Development (CED) study. 

We looked at the file and Medicare rules. The file shows that the enrollee is not in a Medicare-approved CED study for these services. 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 leadless pacemaker insertion.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that the Vertiflex procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.