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

We decided that the Plan does not have to pay forcrowns over your previously received dental implants.You asked the Plan to pay forthe crowns. You say that you would like for this procedure to be authorized, paid for, and completed as promised. You also say that you believe the Plan should cover the whole procedure going forward.The Plan denied your request. The Plan says coverage of dental implants and any prosthetic devices, including crowns, attached to or covering dental implants are excluded from coverage.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 itemsor services are not among those covered under this benefit. The contract clearly states that dental implants, including bone augmentation and fixed or removable prosthetic devices attached to or covering the implants are not covered.Therefore, we decided that the Plan does not have to pay forcrowns over your previously received dental implants.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 that the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimum assist for functional transfers and activities of daily living, and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe crown on tooth #15 and crown on tooth #12. We decided that the Plan does not have to pay forthe two prefabricated post and cores and endodontic therapy.  You asked the Plan to pay forthe two prefabricated post and cores, endodontic therapy,crown on tooth #15, and crown on tooth #12. You say that you needed a lot of dental work done and you sat down with the finance department to determine what was the best route to go on.You also say that these services were denied for incorrect reasons.The Plan says that prefabricated post and core in addition to crown and endodontic therapy are not covered benefits. The Plan also says that the provider or group who rendered the crowns is excluded from receiving payment for services performed according to the U.S. Office of the Inspector General.We decided that the Planhas to pay forthe crown on tooth #15 and crown on tooth #12. 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 says that the provider that rendered these services is excluded from receiving payment. The Plan did not provide evidence that this provider was excluded from coverage on the August 30, 2019 date of service.Therefore, we decided that the Plan has to pay forthe crown on tooth #15 and crown on tooth #12. We also decided that the Plandoes not have to pay forthe two prefabricated post and cores and endodontic therapy.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 Medicarecoverage, prefabricated post and core in addition to crown and endodontic therapy are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe two prefabricated post and cores and endodontic therapy.If the Plan does 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 to review. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy Autocode test strips for the enrollee.You asked the Plan to pre-approve these services. You say that these are medically necessary.The Plan denied your request. The Plan says that there is no medical reason documented that the enrollee is medically unable to use the preferred meters.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.The items at issue are Prodigy Autocode test strips. Prodigy Autocode is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers.Therefore, we decided that the Plan does not have to pre-approveProdigy Autocode test strips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided by Out of Network (OON) provider, on May 22, 2019.You asked the Plan to waive the coinsurance for DME. You say that you cannot afford the charges and suffered an allergic reaction.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for high cost DME and related supplies.You received DME on May 22, 2019. The allowed amount is $2,850 and 20% of that is $570. You have been asked to pay the total coinsurance amount of $570 for DME. DME falls within the DME and related 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 coinsurance forDME provided by Out of Network (OON) provider, on May 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fordiagnostic mammograms and ultrasounds provided on September 16, 2019.You asked the Plan to waive the copayments fordiagnostic mammograms and ultrasounds. You say that you disagree with the charges and feel that the technicians should pay the charges due to the error.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 basic imaging service.You received diagnostic mammograms and ultrasounds on September 16, 2019. Therefore, you are responsible to pay a $40 copayment per each service. The total amount you owe is: $80. You have been asked to pay the total copayment amount of $80 for diagnostic mammograms and ultrasounds. Diagnostic mammograms and ultrasounds fall 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 copayments fordiagnostic mammograms and ultrasounds provided on September 16, 2019.We note your complaint that you received the diagnostic services due toan errorandthat younever received the results. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99201, CPT 72040) you received on September 27, 2019, or waive the copayment for the services (CPT 98941) you received on October 7, 2019, and October 11, 2019.You asked the Plan to pay for the services. You say that you should not have to pay anything.The Plan denied your request. The Plan says the claim processed correctly.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 $20 copayment for each Medicare-covered chiropractic visit. The records show that you were provided Medicare-covered chiropractic services on October 7, 2019, and October 11, 2019. You have been asked to pay a $20 copayment for each visit. The services fall within the chiropractic 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.The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services (CPT 99201, CPT 72040) you received on September 27, 2019, were not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay forthe chiropractic services (CPT 99201, CPT 72040) you received on September 27, 2019, and to waive the copayment for the services (CPT 98941) you received on October 7, 2019, and October 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the post-cataract laser surgery provided on November 13, 2019.
You asked the Plan to waive the copayment for the post-cataract laser surgery. You say that you were told that the laser treatment would be covered. You say the laser treatment is not the same as surgery. The Plan denied your request. The Plan says you have been charged 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 $175 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $175 copayment for the post-cataract laser surgery. The post-cataract laser surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the post-cataract laser surgery is considered a surgical procedure.
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 post-cataract laser surgery provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe root canal (D3330) provided on October 21, 2019.You asked the Plan to pay forthe dental service. You say that you were advised by a plan representative that medically necessary root canals are covered.The Plan denied your request. The Plan says root canals are dental in nature. The Plan says that root canals are not a covered service.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 root canal is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe root canal (D3330) provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora specialist office visit provided on June 5, 2019 by an out of network (OON) provider.You asked the Plan to pay for a specialist office visit. You say that these services were referred to your mom after being discharged from the hospital due to a double pelvic fracture.The Plan denied your request. The Plan says these services were self-referred. The Plan says that no prior authorization was obtained for these services.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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve theitem/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora specialist office visit provided on June 5, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3 for the enrollee.You asked the Plan to pre-approveGelsyn-3. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicatesthat 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 Gelsyn-3. Our physician reviewer found that the enrollee has unilateral primary osteoarthritis of the right knee. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drug. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approveGelsyn-3 for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on November 8, 2019.You asked the Plan to pay for the electric stimulation therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPTcode 97014 has a status code of I.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 CPT code 97014 is not supported in the record. Specifically, CPT code 97014 has a status code of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on November 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.You asked the Plan to pre-approve a power mobility device. You say that you need a power mobility device.The Plan denied your request. The Plan says criteria is not met.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by your 4-wheeled walker. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty wheelchair.You asked the Plan to pre-approve a heavy duty wheelchair (K0006). You say that the enrollee feels a standard wheelchair will break down quickly.The Plan denied your request. The Plan says they will approve a standard wheelchair but criteria is not met for a heavy duty wheelchair.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy duty wheelchair (K0006) have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy duty wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four retainer crowns, five surgical placements of implant bodies: endosteal implants, implant supported porcelain/ceramic crown, three pontics, and five custom fabricated abutments.
You asked the Plan to pre-approve the retainer crowns, endosteal implants, crown, pontics, and custom fabricated abutments. You say that the implant treatment is needed in order for you to masticate food into a small enough bolus for adequate digestion. You also say that without this treatment, you will not be able to eat solid foods and will ultimately no longer thrive and succumb to a myriad of illnesses. The Plan denied your request. The Plan says neither Medicare nor your Medicare Advantage health plan covers these items.
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, implant services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four retainer crowns, five surgical placements of implant bodies: endosteal implants, implant supported porcelain/ceramic crown, three pontics, and five custom fabricated abutments.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided August 12, 2019 to August 14, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were provided in good faith and medically reasonable and necessary. The Plan denied your request. The Plan says that the clinical information provided is not sufficient to support an inpatient hospital level of service.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was first admitted under observation status after experiencing nausea/vomiting, persistent diarrhea, abdominal pain and changed to inpatient admit on 08/13/19 when tested positive for salmonella. By 08/14/19, improvement was noted. He was d/c home in stable condition. The review indicates that the patient required medically necessary hospital care that was expected to span 2 or more midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided August 12, 2019 to August 14, 2019.
If the Plan does 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 to review. The Plan has to show us the mistake and/or send 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.You asked the Plan to pre-approve the dental services. You say that you need these services as you have cavities under your gum.The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service.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 not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided September 17, 2019 to September 24, 2019.You asked the Plan to pay for the inpatient hospital services. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. The records provided are not for the dates of service of this claim and the plan has made multiple attempts to obtain the records.We looked at the file and Medicare rules. 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 forthe inpatient hospital services provided September 17, 2019 to September 24, 2019.