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

We decided that the Plan does not have to waive the copayment for the ambulance transportation received January 26, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the hospital committed fraud against the Plan. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $290 copayment for Ambulance Services. You have been asked to pay a $290 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation received January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for teeth #13 and 20 (D3320).
You asked the Plan to pre-approve endodontic therapy for teeth #13 and 20. You say that the services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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 one root canal per calendar year. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of endodontic therapy for teeth #13 and 20 have not been met. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy for teeth #13 and 20 (D3320).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Breztri Aerosphere inhaler.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Breztri Aerosphere inhaler.
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided October 7, 2020.
You asked the Plan to pay for the comprehensive oral exam and panoramic x-rays. You say that the provider is in-network as of October 1, 2020 and the claim should be re-processed as such. The Plan denied your request. The Plan says there is no coverage when services are rendered 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. The Plan covers the comprehensive oral exam and panoramic x-rays when the services are provided by a network provider.
We looked at the file and Medicare rules. In this case it appears that services were provided by an out-of-network provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam and panoramic x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image (D0330) provided October 7, 2020.
Non-contract provider appeals require a Waiver of Liability form indicating that the enrollee is not being held responsible for the items or services at issue. In this case, you signed and completed a Waiver of Liability form, indicating that you are a non-contract provider.
You claim that you are a contract provider with the Plan. Contract providers do not have appeal rights through the Independent Review Entity (IRE) process. If you are indeed a contract provider with the Plan, you will need to contact the Plan directly regarding any appeal processes that they have for contract providers.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.
You asked the Plan to pre-approve the Intracept Procedure. The Plan denied your request. The Plan says this is
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 the Intracept Procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the Intracept Procedure is experimental. More research is needed to show safety
and efficacy of the procedure.
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 Intracept Procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept Procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gastrointestinal (GI) tract capsule endoscopy (91110).
You asked the Plan to pre-approve Gastrointestinal (GI) tract capsule endoscopy (91110). You say that the requested GI tract capsule endoscopy (91110) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Gastrointestinal (GI) tract capsule endoscopy (91110).
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 Gastrointestinal (GI) tract capsule endoscopy (91110). Our reviewer says that the enrollee does not meet criteria for the requested Gastrointestinal (GI) tract capsule endoscopy (91110). Our physician reviewer found the enrollee has been concomitantly scheduled for EGD, colonoscopy, and wireless capsule endoscopy (WCE) all on the same day. Per a 5/7/2021 telemedicine visit, the enrollee has gastroesophageal reflux with associated Barrett's esophagus (identified by EGD 1/2/2019), occult blood in stool, and a history of serrated colon adenoma (last colonoscopy was 1/2/2019) with family history of colon cancer in uncle. Provided coverage criteria approves WCE for member's occult blood in stool were he to have had within the last 12 months an EGD and colonoscopy that failed to identify a GI bleeding source. Member does not meet this coverage requirement. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gastrointestinal (GI) tract capsule endoscopy (91110) have not been met. Therefore, we decided that the Plan does not have to pre-approve Gastrointestinal (GI) tract capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan
denied your request. The Plan says Vertiflex surgery is experimental/investigational.
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 Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy before this will be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. 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 has a past medical history of stroke, Alzheimer's disease, diabetes and hypertension and is living at home with frequent falling and weakness. 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy butthere is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided fromAugust 31, 2020, through September 11, 2020.You asked the Plan to pay for the continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services is not reasonable and necessary under Medicare guidelines. 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 pay for the continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee no longer qualified for SNF coverage.The enrollee did not have documented skilled nursing needs.The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long-term 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 continuation of SNF services have not been met.Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from August 31, 2020, through September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.You asked the Plan to pre-approve IRF care.The Plan denied your request. The Plan says admission to rehabilitation hospital 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 that t complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke with right sided weakness and you were admitted for reversal of loop ileostomy. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from October 8, 2020, to November 3, 2020.You asked the Plan to pay forSNF services provided from October 8, 2020, to November 3, 2020. You say that the services are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee was discharged from physical and occupational therapy services as of October 7, 2020. The Plan also says that the enrollee was no longer receiving skilled 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 pay for SNF services provided from October 8, 2020, to November 3, 2020. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment ofa skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient 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 services provided from October 8, 2020, to November 3, 2020 have not been met.Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from October 8, 2020, to November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable contraception.

You asked the Plan to pre-approve Etonogestrel (contraceptive) implant system, including implant and supplies
(J7307). You say that the enrollee needs this implant system. The Plan denied your request. The Plan says
contraceptive supplies are not a covered benefit.

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 Etonogestrel (contraceptive) implant
system, including implant and supplies (J7307).

We looked at the file and Medicare rules. Medicare does not cover this implant. Based on this information, we
decided that Medicare rules for coverage of Etonogestrel (contraceptive) implant system, including implant and
supplies (J7307) have not been met. Therefore, we decided that the Plan does not have to pre-approve
implantable contraception.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy or by Medicare for your condition.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) (D7250) and the alveoloplasty in conjunction with extractions (D7310) received December 8, 2020.
You asked the Plan to pay for the dental services (D7250, D7310). You say that you have not used your dental benefit before and therefore The Plan denied your request. The Plan says you have a $1,000 benefit allowance maximum for 2020. You exhausted this benefit and are responsible for any amount billed over this benefit maximum.
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 payment is in excess of
that which is covered under this benefit. Prior to the December 8, 2020 date of service, you used $215 of your $1,000 allowance. On December 8, 2020 you used the remainder of this benefit allowance ($785). The Plan contract states you are responsible for any amount over and above the benefit allowance. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) (D7250) and the alveoloplasty in conjunction with extractions (D7310) received December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interlaminar/interspinous process device.You asked the Plan to pre-approveInsertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867).You say that the enrollee needs this device for chronic low back pain relief.The Plan denied your request. The Plan says there are not enough studies to show the device is safe and effective to treat back pain.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 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867)have not been met.Therefore, we decided that the Plan does not have to pre-approvean interlaminar/interspinous process device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.You asked the Plan to pre-approve a grab bar. You say that this is medically necessary for your mother to walk to the bathroom.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approvehome health aide services. You say that you feel that your primary care physician is not sending the correct information.The Plan denied your request. The Plan says there is no record of a physician order for a home health aide.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide services.