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

We decided that the Plan does not have to reimburse you forthe 3 1 surface fillings (D2330), the 2 surface filling (D2392), and the 4 surface filling (D2335) provided from June 11, 2019 to September 4, 2019.You asked the Plan to reimburse you forthe dental services. You say that the services you received should be covered.The Plan denied your request. The Plan says the provider in this case is not a participating provider. The Plan also says that services received out of network 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 and fillings are a covered service, they are not covered when you receive the services out of network.Therefore, we decided that the Plan does not have to reimburse you forthe 3 1 surface fillings (D2330), the 2 surface filling (D2392), and the 4 surface filling (D2335) provided from June 11, 2019 to September 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee fell while trying to turn off her air conditioner. You say that her aide called for an ambulance and the responders came and evaluated the enrollee for any injuries. After determining that the enrollee was okay, it was decided that transport to the emergency room was not necessary. You say that calling the ambulance was the correct thing to do as the enrollee could have been hurt.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 August 14, 2019. 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 forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the peripicalx-ray (D0220), and the crown (D2752) for tooth # 9 provided from September 9, 2019 to September 30, 2019.You asked the Plan to pay forthe dental services. You say that you were never advised that the services would not be covered.The Plandenied your request. The Plan says the dental services that you received are not listed as covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan'scoverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the peripical x-ray (D0220), and the crown (D2752) for tooth # 9 provided from September 9, 2019 to September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided from January 30, 2019 to August 7, 2019.You asked the Plan to pay forthe periodontal maintenance. You say that due to long standing periodontal disease you need to have your teeth cleaned every 3-4 months in order to avoid further gum erosion. You also say that the Plan pays for dental cleanings 2 times a year and periodontal maintenance is a dental cleaning, just a more intense cleaning.The Plan denied your request. The Plan says this service is not covered 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.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance provided from January 30, 2019 to August 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were experiencing angina pain in your chest and your spouse called for an ambulance. After arriving, the responders evaluated you and ran some tests. You say that your vitals stabilized and you declined transportation to the hospital, however the EMT visit was absolutely necessary. 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 August 24, 2019. 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.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient, and nail debridement provided on August 10, 2019.
You asked the Plan to pay for the physician services. You say that the services you provided to the enrollee were not related to hospice. You also say that care outside of hospice must be covered by the Medicare Advantage Plan. The Plan denied your request. The Plan says during the election, fee for service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. The Plan also says that it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage memeber on hospice.
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 the home visit for the evaluation and management of an established patient, and nail debridement provided on August 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Gel-One injection for the enrollee.You asked the Plan to pre-approvethe injection. You say that this is medically necessary.The Plan denied your request. The Plan says the off-label use of this drug is not covered.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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is insufficient evidencethat Gel-One is effective for osteoarthritis of the shoulder. The requested Gel-One intra-articular injection of the right shoulder is not considered medically reasonable and 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 the injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea Gel-One injection for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on October 31, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on October 19, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the inpatient hospice care providedfrom April 29, 2019 to May 4, 2019.
You asked the Plan to issue reimbursement for the inpatient hospice care. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 4, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to issue reimbursement for the inpatient hospice care provided April 29, 2019 to May 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).You asked the Plan to pre-approveSNF stay. You say that the enrollee's quality of life is at risk and going back home alone in her current condition would not help her recover.The Plan denied your request. The Plan says the denial of authorization for SNF admissionis correct.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 stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF stay have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bacterial decontamination period therapy (D4999 x 4), the prescription drug (D9630 x 4), oral hygiene instruction (D1330 x 2), oral or facial photographic imaging (D0350), and the gingival irrigation (D4921 x 4) provided from July 10, 2019 to October 17, 2019.
You asked the Plan to reimburse you for the bacterial decontamination period therapy, the prescription drug, oral hygiene instruction, oral or facial photographic imaging, and the gingival irrigation. You say that you were not informed that the dentist was not in contractual agreement since 2018. You also say that you go the referral from the Plan website for the treatment. The Plan denied your request. The Plan says the bacterial decontamination period therapy, the prescription drugs, oral hygiene instruction, oral or facial photographic imaging, and the gingival irrigation are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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 reimburse you for the bacterial decontamination period therapy (D4999 x 4), the prescription drug (D9630 x 4), oral hygiene instruction (D1330 x 2), oral or facial photographic imaging (D0350), and the gingival irrigation (D4921 x 4) provided from July 10, 2019 to October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve3physical therapy (PT) and 3 occupational therapy (OT) home health visits.You asked the Planto pre-approve3 PT visits and 3 OT visits. You say that these services are medically necessary.The Plandenied your request. The Plansays these services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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-approve3additional PT visits and 3 OT visits. Our reviewer says that the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for you. Our physician reviewer found that you are ambulating 120 feet with modified independence, good lower extremity strength, and good upper body strength. Based ontheavailable records, you donot meet criteria for coverage of the requested 3PT and 3 OT visits.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3PT visits and 3 OT visitshave not been met.Therefore, we decided that the Plandoes not have to pre-approve3physical therapy (PT) and3 occupational therapy (OT) home health visits.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approvekidney transplant for the enrollee.You asked the Planto pre-approvethe transplant. You say that this is medically necessary for ESRD.The Plandenied your request. The Plansaysthatthere is no documentation of cardiac clearance, or of a repeat EKG.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 transplant. Our reviewer says that the requested transplant is considered medically reasonable and necessary in this case. Our physician reviewer found the concerns are notable, but the decision as to whether a patient is a renal transplant candidate is up to the transplant center. They have a process for patients such as thisto determine their suitability for transplant. The center may recommend therapy, drug testing, and may have the patient have other goals/criteria that need to be met before agreeing to place on the list of transplant eligibility. He is acceptable for transplant evaluation. Patients with greater challenges than his have received transplants successfully.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 transplant have been met.Therefore, we decided that the Planhas to pre-approvekidney transplant for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information toreview. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service your wife called 911 because you were acting aggressive because of your low blood sugar. The responders came and after treatment you began to feel better. The responders advised you that you should go to the hospital however you declined because you stated that there would be the extra expense as well as waiting for a long period of time. You say that you should not be responsible for the cost of the ambulance response services. 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 12, 2019. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.
You asked the Plan to pay for incontinence supplies. You say that you were told by the provider that the incontinence supplies would be free for the first order. You say that you called the provider several times and were told you should not be charged. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiotherapy for the enrolle.You asked the Plan to pre-approvethe requested services. You say that the enrollee is a good candidate for proton beam therapy as part of his treatment due to dose reduction to his heart.The Plan denied your request. The Plan says research has not shown this type of treatment to be helpful for treating the enrollee's cancer.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 requested services. Our physician reviewer found that proton therapy is not investigational, but rather an FDA approved tool available to clinicians to treat with radiotherapy. However, any potential benefit over non-proton based IMRT or VMAT is investigational.  For esophageal cancer, proton therapy is not likely to be medically necessary. There is a paucity of data to support its use, which would be supported for exceptional cases, and while thereare some dosimetric advantages, there are other dosimetric disadvantages. For this enrollee, the potential dosimetric advantage does not appear to be clinically meaningful. As such, proton therapy is not considered medically necessary for this enrollee, as the routine use of proton therapy for esophageal cancer would not be considered standard medical practice.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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approveproton beam radiotherapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on September 4, 2019.
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says this service is not covered by your plan. The Plan also says that they confirmed that you were not enrolled in the supplemental in 2019.
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 for the crown provided on September 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the services should be covered.The Plandenied 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 22, 2019. 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 forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral hygiene instructions, periodic oral evaluation, and topical application of fluoride varnish provided on November 14, 2019.You asked the Plan to pay forthe oral hygiene instructions, periodic oral evaluation, and topical application of fluoride varnish. You say that you have preventive coverage and were charged for an oral evaluation.The Plandenied your request. The Plan says oral hygiene instructions and topical application of fluoride varnish are not covered benefits. The Plan also says that the benefit maximum for the time period or occurrence had been reached for the periodic oral evaluation.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, oral hygiene instructions and topical application of fluoride varnish are not among those covered under this benefit. The contract also clearly states that oral examinations are limited to one per year. The record shows that you received a periodic oral evaluation on October 25, 2019, and your oral examination benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe oral hygiene instructions, periodic oral evaluation, and topical application of fluoride varnish provided on November 14, 2019.