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

We decided that the Plan has to pay for a contact lens fitting (92310) provided on January 7, 2021.
You asked the Plan to pay for the contact lens fitting. You say that your contract says you have a $200 allowance that can be used toward the purchase and fitting of eyewear, so the Plan should cover your contact lens fitting. The Plan denied your request. The Plan says that this service is not covered by Medicare or by your supplemental vision benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 for the purchase and fitting of eyewear each year. We looked at the file and the Plan's rules. The service at issue is a contact lens fitting. The Plan was billed $140 for the eyewear purchased on the same date, so there is still money from the $200 allowance. The Plan's contract states that this allowance is to be used toward the purchase and fitting of routine eyewear. Based on this information, we decided that the Plan's rules for coverage of the contact lens fitting. have been met. Therefore, we decided that the Plan has to pay for a contact lens fitting (92310) provided on January 7, 2021, up to the amount allowed by the annual allowance.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay provided from September 1, 2020, through
September 23, 2020.

You asked the Plan to pay for the inpatient stay. The Plan denied your request. The Plan says the authorization
expired on September 1, 2020.

The Plan contract says except for emergency care, we cannot pay a provider who is not eligible to participate in
Medicare.

We looked at the file and the Plan's rules. The file shows that the authorization expired on September 1, 2020.
Therefore, we decided that the Plan does not have to pay for an inpatient stay provided from
September 1, 2020, through September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 low air loss mattress for the enrollee.

You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of multiple stage two pressure ulcers on the trunk or pelvis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mattress. Our reviewer says that the requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal evidence of large or multiple stage 2 or stage 3 pressure ulcers on the trunk or pelvis. There is no history of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 

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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 low air loss mattress for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery (43644, 43659).

You asked the Plan to pre-approve bariatric surgery. You say that the enrollee has failed to lose weight on
many diets. The Plan denied your request. The Plan says there is no indication that the member was not initially
successful at losing weight.

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 bariatric surgery. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found although this patient is morbidly obese, the patient already underwent gastric bypass procedure
in 2004, so the NCD guidelines are not applicable. The patient has no anatomic complications of the gastric
bypass that are noted. The requested procedure to either perform a sleeve gastrectomy or revision gastric
bypass on normal gastric bypass anatomy is not a standard procedure and would be considered investigational
given lack of published evidence to support this as a safe, effective or durable treatment for post gastric bypass
weight regain.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve bariatric surgery (43644, 43659).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the clinical information does not support the medical necessity of SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the acute hospital on July 4, 2021, with acute, intractable back pain with radiculopathy. She was treated in the hospital with analgesics and anxiolytics and improved. She is weak and deconditioned and is working with physical therapy. She is walking 30 feet with a rolling walker with contact guard assistance and is contact guard assist for sit to stand transfers. There were no occupational therapy notes submitted. She is reported to be medically stable for discharge. There is no documentation that the enrollee requires skilled nursing services. There is a need for skilled therapy services, but not on a daily basis. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 an IRF stay is medically necessary to provide the enrollee with physical medicine and rehabilitation oversight and medical supervision to get him home safely and back to work. You say that the enrollee is motivated to get home. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a infection of the toe and had amputation of the toe. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 5, 2020.
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 physician's services provided on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of IV moderate (conscious) sedation/analgesia (D9239) and each subsequent 15 minute increment of IV moderate (conscious) sedation/analgesia (D9243).
You asked the Plan to pre-approve the IV moderate (conscious) sedation/analgesia. You say that the enrollee requires IV sedation due to apprehension. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 first 15 minutes of IV moderate (conscious) sedation/analgesia (D9239) and each subsequent 15 minute increment of IV moderate (conscious) sedation/analgesia (D9243).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 22, 2021.
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 code G0483 is 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 G0483 is definitive drug testing, 22 or more classes.
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. 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 drug testing rendered on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient hospital visit (G0463)
provided on January 8, 2021.
You asked the Plan to waive the deductible for an outpatient hospital visit. You say that you disagree with the
charges. The Plan denied your request. The Plan says the deductible you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $203 deductible for covered medical services.
The service at issue is subject to the Plan deductible of $203. The record shows that at the time this claim was
processed, $56.43 of the $203 deductible had been met. The allowed amount of the claim is $114.04, resulting
in a deductible obligation of $114.04. The record shows that the billing provider in this case was the hospital.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for
covered medical services. This cost sharing is a contractual obligation that had not been met at the time an
outpatient hospital visit was received on January 8, 2021. Therefore, we decided that the Plan does not have to
waive the deductible for an outpatient hospital visit (G0463) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), a fixed partial denture sectioning (D9120), an implant removal (D6100), and re-cement or re-bond of a crown (D2920) provided on February 13, 2021.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, a fixed partial denture sectioning, an implant removal, and re-cement or re-bond of a crown. You say that the services at issue should be covered. The Plan denied your request. The Plan says the services at issue 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 pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), a fixed partial denture sectioning (D9120), an implant removal (D6100), and re-cement or re-bond of a crown (D2920) provided on February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (D6100) provided on March 16, 2021.
You asked the Plan to pay for the dental service. You say that the implant had been in for several years. You say that it began causing pain and bone loss. You say that the dentist also had to do a bone graft to restore the jaw in that area. You say that you understand that the placement of an implant and a bone graft are not covered by the plan, but you say that the removal of an implant should be. You also say that you should be reimbursed for the service. The Plan denied your request. The Plan says implant removal 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 implant removal not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant removal (D6100) provided on March 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 15, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
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 March 15, 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 the ambulance services provided on March 15,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care you received from February 9, 2021, to February 17, 2021.
You asked the Plan to waive the copayment for the inpatient mental health care. You say that you cannot afford this bill and you shouldn't have to pay it. The Plan denied your request. The Plan says you were charged this copayment 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 $100 copayment per day for days 1-8 for inpatient mental health care. You have been asked to pay a $100 copayment per day for days 1-8 for the inpatient mental health care. This copayment applies regardless of the reason for the services. 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 inpatient mental health care you received from February 9, 2021, to February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (84439, 84443, 36415) provided on January 29, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you would like this claim to be paid. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 freestanding laboratory visit. You have been asked to pay a $40 copayment for laboratory services. The EOC confirms that $40 is the required copayment for this service. You have been asked to pay a copayment of $23.40, which is less than the Plan's contracted amount. 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 laboratory services (84439, 84443, 36415) provided on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral evaluation (D0120) and an intraoral-periapical X-ray (D0220) provided on January 19, 2021, by an out of network provider.
You asked the Plan to pay for an oral evaluation and an intraoral-periapical X-ray. You say that you have been under the provider's care since September 2015. The Plan denied your request. The Plan says rules for dental care have not been met.
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 an oral evaluation when provided by an in-network provider. We looked at the file, the Plan contract, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an oral evaluation and an intraoral-periapical X-ray have not been met. Therefore,
we decided that the Plan does not have to pay for an oral evaluation (D0120) and an intraoral-periapical X-ray (D0220) provided on January 19, 2021, by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that it is medically necessary for the enrollee to receive the requested continuous glucose monitor over the Plan's preferred brand.
The Plan denied your request. The Plan says it is not medically necessary for the enrollee to use a device other than the Plan's preferred brand.
The Plan follows Medicare rules. Medicare rules say that they are allowed to select certain brands as 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 a Dexcom G6 continuous glucose monitor. Our reviewer says that the requested Dexcom G6 continuous glucose monitor is not medically necessary and reasonable. Our physician reviewer found a continuous glucose monitor is indicated but there is no data here to prove why a Dexcom G6 is needed instead of the Plan's preferred Freestyle Libre 2. The Freestyle Libre 2 would also provide alerts for high and low blood glucose levels as long the reader is kept within a few ft of the patient. It is unclear and not specified why the patient is not able to swipe her reader in front of the sensor to garner blood glucose data. In conclusion, it is not medically necessary to use the Dexcom G6 over the Plan's preferred brand. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.