Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided at a lower level of care, like in a long-term care facility or at home with home health services.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that the fracture of the buccal porcelain is causing marginal leakage around the buccal margin of the composite sealing the access opening. You also say that a new full coverage restoration with buildup for retention form is indicated to restore this tooth to optimum strength and function and to allow it to properly serve as an abutment for the maxillary cast. The Plan denied your request. The Plan says this service is not a covered 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 a core buildup, including any pins when required (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 testing services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are experimental/investigational and not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back, upper back, and neck pain. The requested Intracept procedure is considered experimental in nature, as more research is needed to support safety and efficacy. The services are therefore 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 an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for periodic oral exam (D0120) prophylaxis (D1110) bitewing 4 x-rays (D0274) resin-based composite (D2392) provided June 17, 2019 to June 20, 2019.
You asked the Plan to waive the copayment for the dental services. You say that you had no knowledge that this provider was out of network. You would have seen the other provider who is in-network had you knew this information. The Plan denied your request. The Plan says the 20% cost share was applied correctly for the covered codes D0120 and D1110. D0274 and D2392 are not listed and therefore is not covered.
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 out of network dental services.
You have been asked to pay $340.20 for the dental services. The bitewing x-rays and filling are not listed and is therefore not covered. The dental services fall within the Dental Services-Supplemental 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 periodic oral exam (D0120) prophylaxis (D1110) bitewing 4 x-rays (D0274) resin-based composite (D2392) provided June 17, 2019 to June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmologist office visit to be provided by an out
of network (OON) provider.
You asked the Plan to pre-approve an ophthalmologist office visit. You say that you would like approval for
this provider. The Plan denied your request. The Plan says there are multiple in-network providers available 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an ophthalmologist office visit to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ED visit provided on October 15, 2019.You asked the Plan to pay for the ED visit. 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 enrollee's terminal condition.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 ED visit provided on October 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 8, 2019 to December 7, 2019.

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 the services were not medically necessary.

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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. She was effectively treated for pain. She received physical and occupational therapy in the SNF. By the dates in question, she was independent to supervision level for functional mobility, including gait to 150 feet with a rollator walker. She needed varied assistance with activities of daily living. She had no skilled nursing or skilled therapy needs. She did not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of care.

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 pay for the skilled nursing facility (SNF) services rendered from November 8, 2019 to December 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient surgical center services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the outpatient surgical center services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to seek out-of-network care. The Plan says that your surgeon has in-network privileges at the medical center. 
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient surgical center services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that you needed to have 5 teeth removed. You also say that you need this denture in order to be able to chew. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago.
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, dentures are limited to one set every 5 years. The record shows that you received a maxillary partial denture on March 6, 2017 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 19.
You asked the Plan to pre-approve the core build up. You say that a full coverage restoration with full build up
for retention form will be necessary to restore tooth # 19to optimum strength and function. The Plan denied
your request. The Plan says core build up 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, the requested core build up is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core
build up (D2950) for tooth # 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035).
You asked the Plan to pre-approve the custom breast prosthesis. You say that the prosthesis is medically necessary. The Plan denied your request. The Plan says custom breast prostheses are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a custom fabricated prosthesis is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custom breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
You asked the Plan to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments. The Plan denied your request. The Plan says you do not meet the criteria established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020.
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's debit card allowance benefit. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult daycare services.
You asked the Plan to pre-approve these services. You say that the enrollee would benefit from the services. The Plan denied your request. The Plan says the services are not covered.
The rules say that in order to be reimbursed by the health plan or Medicare for services provided to enrollees, the provider of services must be Medicare-certified to receive payment for services rendered to enrollees. We looked at the file and Medicare rules. The requested services are adult daycare services. Adult daycare centers are generally not Medicare-certified facilities. Therefore, we decided that the Plan does not have to pre-approve adult daycare services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided out of network on June 7, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided out of network on June 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prefabricated post and core in addition to crown (D2954) and crown (D2740) for tooth #28.
You asked the Plan to pre-approve the prefabricated post and core and crown. You say that the tooth itself is broken, and this is why the original crown came off and exposed the nerve. You also say that the tooth broke and the old crown could not be re-used. The Plan denied your request. The Plan says prefabricated post and core in addition to crown is not a covered benefit. The Plan also says that you received a crown less than 84 months ago
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, prefabricated post and core in addition to crown (D2954) is not among those covered under this benefit. The contract also clearly states that crowns, codes D2710-D2794, are limited to once every 84 months per tooth. The record shows that you received a crown (D2740) on tooth #28 on August 11, 2017 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve the prefabricated post and core in addition to crown (D2954) and crown (D2740) for tooth #28.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the anesthesia services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the anesthesia services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent
to seek out-of-network care. The Plan states there are in-network specialist's available to you that can provide
the care you are requesting.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the anesthesia services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Stiolto Respimat Inhaler for the enrollee.You asked the Plan to pre-approve the inhaler. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.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 Stiolto Respimat Inhaler for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve video electroencephalogram (EEG) monitoring.
You asked the Plan to pre-approve these services. You say that you have seizures and want the monitoring. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you have a history of post-traumatic epilepsy with a history of seizures. At the time of the most recent neurology visit, you reported new types of possible seizures that had not been previously present. In this setting, it is the standard of care to initiate further evaluation with EEG to classify the cause of the events. The information from the EEG can be used to guide future treatment planning. The requested video EEG monitoring is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve video electroencephalogram (EEG) monitoring.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a  procedure (43284).
You asked the Plan to pre-approve a  procedure. You say that this procedure will benefit the patient. The Plan denied your request. The Plan says this procedure is not covered.
The Plan must follow Medicare rules. Medicare rules say that coverage is not available for Reflux Management System, which is not considered reasonable and necessary for the diagnosis or treatment of an injury or disease. We looked at the file and Medicare rules. The requested  procedure is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of a  procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a procedure (43284).