Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are 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 that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee 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 the enrollee is 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 Plan. 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided January 23, 2021 to
February 1, 2021.

You asked the Plan to pay for the inpatient hospital services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that the inpatient services are not supported in the medical record. Specifically, the Present on
Admission (POA) Indicator is needed for the listed diagnosis. Based on this information, we decided that
Medicare rules for coverage of the inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital services provided January 23, 2021 to February 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography services (93306 x 2) rendered by the out-of-network (OON) provider on December 29, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 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 services at issue in this appeal.
The Plan did not pre-approve the services at issue. 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 the transthoracic echocardiography services (93306 x 2) rendered by the out-of-network (OON) provider on December 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transportation trip.

You asked the Plan to pre-approve a routine transportation trip. You say that you were unaware that the weekend did not count toward business days when getting Plan approval. The Plan denied your request. The Plan says you spoke with member services on Friday, June 11, 2021, and scheduled non-emergency transportation with the Plan's approved vendor for Monday, June 14, 2021. Therefore, you did not allow 48 business hours in advance for plan approval.

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. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a routine transportation trip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement (D6010), custom fabricated abutment (D6057) and implant supported crown (D6065).
You asked the Plan to pre-approve the surgical implant placement (D6010), custom fabricated abutment (D6057) and implant supported crown (D6065). You say that you were left with a temporary bridge that needs to be removed and replaced with crowns and implants. The Plan denied your request. The Plan says the services 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical implant placement (D6010), custom fabricated abutment (D6057) and implant supported crown (D6065)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 30, 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 codes 15736, 25078, and 64722 are not supported.
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 15736 is muscle, myocutaneous, or fasciocutaneous flap; upper extremity. The definition of code 25078 is radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; 3 cm or greater. The definition of code 64722 is decompression; unspecified nerve(s) (specify).
We find that CPT codes 15736, 25078, and 64722 are not supported in the medical record. Specifically, there is no documentation of a muscle, myocutaneous, or fasciocutaneous flap of the upper extremity to support code 15736. There is no documentation of a radical resection of tumor of the soft tissue of the forearm and/or wrist area to support code 25078. There is no documentation of nerve decompression to support code 64722. 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 pay for the surgical services rendered on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified restorative procedure (D2999).
You asked the Plan to pre-approve the unspecified procedure. You say that this treatment is necessary. The Plan denied your request. The Plan says this service is not covered by the enrollee's dental benefit.
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 pre-approve an unspecified restorative procedure (D2999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visits with an out-of-network dentist.

You asked the Plan to pre-approve dental visits for teeth removal and dentures. You say that your inability to eat a proper diet is a medical condition. The Plan denied your request. The Plan says you do not have optional supplemental dental coverage.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve visits with an out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 retainer crowns (D6740) and a pontic (D6250).
You asked the Plan to pre-approve the dental services. You say that the claim for the bridge and a crown for tooth # 2 were denied. You say that a partial was previously approved for tooth # 3. You say that you are afraid to have a one-tooth partial denture in the back of your mouth. You also say that your plan covers 2 crowns per year. The Plan denied your request. The Plan says retainer crowns and pontic are not listed as covered comprehensive dental 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, retainer crowns and a pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 2 retainer crowns (D6740) and a pontic (D6250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (d0140) and amalgam filling (D2150) provided on March 25, 2021.
You asked the Plan to pay for the dental services. You say that these services were urgent and necessary and should be covered. The Plan denied your request. The Plan says you were only enrolled in the mandatory dental benefits on the date in question. These services are not covered by this dental benefit.
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 limited oral evaluation (d0140) and amalgam filling (D2150) provided on March 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 15, 2020.
You asked the Plan to pay for the laboratory services. 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. 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. 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 October 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the step therapy exception criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that these drugs would likely be less effective and/or likely have adverse effects for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
You asked the Plan to pre-approve periodontal scaling and root planing (D4341). You say that you have a disease in your gums that requires deep cleaning. The Plan denied your request. The Plan says code D4341 is only covered on procedure per quadrant every two plan years.
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, periodontal scaling and root planing is only covered once per quadrant every two plan years. The Plan paid for periodontal scaling and root planing in each quadrant provided on September 29, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243).
You asked the Plan to pre-approve intravenous moderate sedation/analgesia. You say that sedation is required for the dental procedure. The Plan denied your request. The Plan says this service is not covered under your 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 20, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell while at your daughter's home and an ambulance came to check on you and provided first aide. You say that you did not want the Plan to have to pay a large medical bill, so you chose not to go to the hospital after the medics had looked at you and determined there was no serious injury. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit and if no transport of a Medicare beneficiary occurs, then there is no Medicare coverage.
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 January 20, 2021. 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 ambulance response and treatment, no transport provided on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine tablet.
You asked the Plan to pre-approve Promethazine tablet. You say that the enrollee is going to undergo treatment for cancer and will need the antiemetic because of the side effects. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The record does not show that the oral antiemetic would be initiated within 2 hours of administration of the chemotherapeutic agent or that it would be used as a full therapeutic replacement for intravenous antiemetic drugs. Therefore, we decided that the Plan does not have to pre-approve Promethazine tablet.
Benefits for Promethazine tablet 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gocovrier.

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 self-administered drugs are not covered.

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 Gocovrier.

Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 23, 2021.
You asked the Plan to pay for the dental services. You say that this was emergency dental work and you did not have time to find a network provider. You say that you were told you would get the money back. The Plan denied your request. The Plan says services must be received from a participating 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin fillings (D2332, D2330), a core buildup (D2950) and a crown (D2750).

You asked the Plan to pre-approve the dental services. You say that these services are important for your dental health. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve resin fillings (D2332, D2330), a core buildup (D2950) and a crown (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).
You asked the Plan to pre-approve the complete upper denture (D5110). You say that they threw away your dentures when you were in the hospital, so you need new ones. You say that you cannot eat without them and you are in desperate need for them. The Plan denied your request. The Plan says D5110 is only covered one procedure per five plan years.
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, a complete upper denture is only covered once every 5 plan years. The Plan paid for a complete upper denture provided on May 19, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110).