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

We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the upper right, upper left, lower right, and lower left quadrants.
You asked the Plan to pre-approve the scalings and planings. You say that you would like to appeal these deep cleanings. The Plan denied your request. The Plan says the x-rays submitted do not show evidence of bone loss or calculus formation on at least 4 teeth in each respective quadrant.
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 scalings and planings 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 scalings and planings. Our reviewer says that the documentation provided does not meet the criteria for coverage for periodontal scaling and root planing in four quadrants (D4341). Our physician reviewer found the documentation did not include a record of the periodontal pockets. Our reviewer also found that the radiographs did not indicate any bone loss or accumulation of subgingival calculus. 
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 scalings and planings have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the upper right, upper left, lower right, and lower left quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on February 3, 2021 by an OON provider.
You asked the Plan to pay for the periodontal maintenance. You say that the representative at the clinic contacted the Plan, and you assumed the service would be covered. The Plan denied your request. The Plan says payment for this service is denied because your plan does not cover services from a provider who is not in network.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on February 3, 2021 by an OON provider.
Please Note: The Plan contacted the provider's office on on May 24, 2021 and was advised that the office has covered the service, leaving you with a $0.00 balance for this date of service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair recliner (A9270).
You asked the Plan to pre-approve a chair recliner. You say that you have bad knees and back pain, and the chair will be able to help you get up from a sitting position The Plan denied your request. The Plan says a chair recliner is a convenience item and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a chair recliner (A9270).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from October 16, 2020, through October 18, 2020.

You asked the Plan to pay for the hospital 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 hospital services provided from October 16, 2020, through October 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on November 12, 2020 and December 2, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you met your maximum out-of-pocket amount and should not be charged the copayments. 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 a $40 copayment for each covered visit or consultation in an outpatient location with a specialist. 
You have been asked to pay a $40 copayment for the specialist office visit on each date of service. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you had not met your maximum out-of-pocket amount when these claims were processed. 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 copayments for the specialist office visits provided on November 12, 2020 and December 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 18, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not aware there was a copayment for this service. You say the provider is not a specialist so there should not be a copayment. 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 a $160 copayment for in-network Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $160 copayment for the ultrasound. 
You have been asked to pay a $117.77 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the ultrasound provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a immediate maxillary partial denture (D5223).

You asked the Plan to pre-approve the immediate maxillary partial denture. You say that you need this denture approved for coverage as soon as possible because it is giving you depression. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve a immediate maxillary partial denture (D5223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

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. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.

We looked at the file and Medicare rules. The file shows that the you inject insulin only once per day. 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 a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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. The patient appears to be unstable and worsening somewhat, requiring only short-term additional acute care services which can be safely be received at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you have doctor's appointments for infusion, oncology, and blood transfusion. The Plan denied your request. The Plan says the transportation trip benefit has been exhausted for the year.
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. The Plan covers a maximum of 20 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries services coded 93880 provided on February 28, 2021.

You asked the Plan to pay for the duplex scan of extracranial arteries services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 93880 is duplex scan of extracranial arteries; complete bilateral study. 

We find that CPT code 93880 is not supported in the medical record. Specifically, this code was submitted without the appropriate modifiers. Based on this information, we decided that Medicare rules for coverage of the duplex scan of extracranial arteries services have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extracranial arteries services coded 93880 provided on February 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 26, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 December 26, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy.
You asked the Plan to pre-approve stereotactic body radiation therapy. You say that the requested treatment is medically necessary. The Plan denied your request. The Plan says medically necessary services once a member is enrolled in a clinical trial are paid for by original FFS Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 
In this case, you asked the Plan to pre-approve stereotactic body radiation therapy as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine PCR panel testing provided on July 15, 2020.

You asked the Plan to pay for urine PCR panel testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is experimental/investigational and urine culture with sensitivity is the standard of care for evaluation of urinary incontinence.

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 pay for urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found urine culture with sensitivity is the standard of care for the valuation of urinary incontinence. Upon review of the records, the clinical presentation did not warrant a focused investigation for possible infection of the urinary tract. Also, there was no mention of urine culture being contraindicated or inappropriate. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for urine PCR panel testing provided on July 15, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aflibercept/Eylea injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary for the enrollee's retinal vein occlusion with macular edema. The Plan denied your request. The Plan says the records provided do not show failure or contraindication to Avastin.

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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has macular edema from central vein occlusion. The requested drug is a new start. There is no trial and failure of the plan's preferred step one agent. The medical record does not indicate that the plan's preferred step one agent would not be appropriate 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Aflibercept/Eylea injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight pharmacogenomic testing provided on January 26, 2021.

You asked the Plan to pay for the testing services. You say that the testing has significant clinical utility and has proven to be a predictor of health outcomes success. The Plan denied your request. The Plan says the testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications. 

We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the medications in question were derived from clinical factors/necessity Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight pharmacogenomic testing provided on January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on December 10, 2020.

You asked the Plan to waive the copay for the services provided. You say that you just had an injection. The Plan denied your request. The Plan says the cost share cannot be waived.

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 $295 copay for outpatient surgery.

The file shows that you received an intravitreal injection at an outpatient hospital facility. This is considered a surgical service. You have been asked to pay a $295 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient surgery services provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.

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 long term acute care hospital (LTACH) services.