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

We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 26, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that you went for your yearly glaucoma exam and 
decided to have a routine eye exam. The Plan denied your request. The Plan says the service at issue is not a 
covered 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 these services when it is performed as a routine screening by a participating 
provider. 
 
We looked at the file and the Plan's rules. An eye refraction is only covered by the Plan when it is performed as 
part of a routine eye exam by a participating provider. The eye refraction was performed as part of a medical 
vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules 
for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for an eye refraction (92015) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2331) provided on March 22, 2021.

You asked the Plan to pay for the dental service. You say that your coverage for comprehensive dental coverage includes a $0 copay or 50% coinsurance with comprehensive coverage including fillings. You also say that you understand there is a $1,000 limit but you have not reached that. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services performed out of network 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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2331) provided on March 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be safely met with home health or in an assisted living facility 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is non-ambulatory and in need of ADL assistance at baseline. The enrollee appears unable to fully participate in daily skilled therapy. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 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) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 29, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered, and you do not agree with the charges. The Plan denied your request. The Plan says the service at issue 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 pay for a limited oral evaluation (D0140) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you had cancer and had
lymphotomy which resulted in removing 3 lymph nodes, which causes for the need of the compression. The
Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), oral hygiene instructions (D1330) and gingival irrigation (D4921) provided on February 5, 2021.

You asked the Plan to pay for the topical application of fluoride varnish (D1206), oral hygiene instructions (D1330) and gingival irrigation (D4921). You say that the treatments are vital for saving your teeth and should be covered at least 50%. You say that the simple solution is to pay 100% until the $1,000 is spent. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), oral hygiene instructions (D1330) and gingival irrigation (D4921) provided on February 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says daily skilled nursing or therapy services are not needed.

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 SNF care. Our physician reviewer found that you presented to the acute hospital with weakness, agitation and a urinary tract infection. You were treated in the hospital with intravenous fluids and antibiotics and improved. You are weak and deconditioned and have been evaluated by physical and occupational therapy. You are not reported to be ambulating. You are at a minimum to moderate assist level for transfers and maximum assist for activities of daily living. You have not been cooperative with therapy due to your cognitive decline and have refused to participate. You do not require the specialized services of a skilled nurse or therapist to provide treatment. You do not require skilled services on a daily basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet injections.

You asked the Plan to pre-approve facet injections. You say that the clinical information provided supports that the requested injections are medically reasonable and necessary. The Plan denied your request. The Plan says that the enrollee does not qualify for coverage of the requested injection services because his pain travels to different areas of his body.

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 facet injections. Our reviewer says that facet injections are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. He is status post laminectomy and foraminotomies from L2-L3 to L4-L5. He has pain on the right side with extension down to the right leg but not below the knee. He has tried ice and heat for the pain. He is taking Gabapentin for pain. He had diagnostic right L2-L5 medical branch blocks (MBBs) and achieved 80% pain relief for 8 hours. The request is for repeat Diagnostic MBBs. The enrollee has lumbar facet syndrome after laminectomy and the request is medically reasonable and 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 facet injections have been met. Therefore, we decided that the Plan has to pre-approve facet injections.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve Orthovisc. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that if the first course of treatment produces relief, subsequent courses of treatment may be reasonable if symptoms return. 

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 Orthovisc. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the enrollee reported no pain relief from a series of Visco-3 on December 20, 2020. The enrollee does not meet the coverage criteria detailed in the LCD. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9945).

You asked the Plan to pre-approve the occlusal guard (D9945). You say that you have chronic TMJ and you grind your teeth a lot. You say that nothing is helping, and you were informed the occlusal guard was covered 100%. The Plan denied your request. The Plan says the 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 the occlusal guard (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records received are not filled out, and do not meet basic rating rules.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no first-hand, narrative, or provider records have been submitted for review. The completed template forms do not document a need for provider, nursing, or rehabilitative services. The requested services appear to be custodial. As such, the requested services are not shown to be medically necessary or reasonable. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve adult day care services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met at a lower level of 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 IRF admission criteria are met. The Plan denied your request. The Plan says IRF care 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 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 fever, peritonitis, and intestinal perforation. The enrollee's medical problems 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on May 6, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images. You say that you were not aware that this provider was out-of-network. You have been to this provider in the past and you want the Plan to pay. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on May 6, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for the collection of a blood specimen from a completely implantable venous access device (36591) provided on February 24, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.

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 does not say in clear and accurate terms how much you should expect to pay for the collection of a blood specimen from an implantable venous access device. 

We looked at the file and your contract with the Plan. Based on this information, we find that you did not have a reasonable expectation that the blood draw through your implanted venous access device would be considered a surgical procedure. While this service may be coded as surgical, the performance of the service would not include many of the components that would reasonably be considered surgery by a layperson. There is no other benefit category in the EOC under which this service would be included other than lab testing. Because of this ambiguity, we find that you cannot be asked to pay more than a $0 copayment for the service at issue. Therefore, we decided that the Plan has to waive the copayment for the collection of a blood specimen from a completely implantable venous access device (36591) provided on February 24, 2020.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OmniSeq Insight Panel testing.

You asked the Plan to pre-approve an OmniSeq Insight Panel testing. You say that the records provided support the need for the requested testing that was ordered by an in-network provider. The Plan denied your request. The Plan says the criteria for coverage have not been met. The Plan says that the requested test is not likely to impact therapeutic decision making in the clinical management and is not considered medically necessary.

The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures may be eligible for coverage when results of the testing directly impact treatment or management of the Medicare beneficiary. 

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 an OmniSeq Insight Panel testing. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has poorly differentiated non-small cell carcinoma of the lung. OmniSeq is a comprehensive genomic and immune profiling assay for solid tumors which interrogates the exonic coding region of 523 genes by next generation sequencing. The available documentation does not demonstrate that OmniSeq Insight Panel testing will directly impact treatment or management of the enrollee in this case. Additionally, it has not been shown that the number of genes in the OmniSeq Insight Panel is reasonable and necessary to obtain the necessary information for therapeutic decision making.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OmniSeq Insight Panel testing have not been met. Therefore, we decided that the Plan does not have to pre-approve OmniSeq Insight Panel testing.