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

We decided that the Plan does not have to pre-approve endodontic treatment for teeth # 22, 23, 24, 25, 26 and 27.

You asked the Plan to pre-approve the dental services. You say that you are unable to eat. You also say that you are afraid you are going to swallow a loose tooth while you are sleeping. The Plan denied your request. The Plan says these teeth have had previous root canal treatments. The Plan also says that endodontics are limited to once per tooth, per lifetime.

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 dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the endodontic treatment does not meet the criteria for coverage. Our physician reviewer found the provided documentation shows that endodontic treatment has been previously performed on teeth # 22, 23, 24, 25, 26 and 27. Therefore the reviewer found that the requested services do not meet the criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve endodontic treatment for teeth # 22, 23, 24, 25, 26 and 27.
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. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary, the enrollee does not require complex daily 
nursing care or skilled therapies. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs and the beneficiary does not require skilled nursing or therapy services on a daily basis. This 
beneficiary does 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 SNF care have not been met. Specifically, the enrollee does not need daily 
skilled services. This means the service is not medically necessary or reasonable. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our physician reviewer found that the enrollee was admitted to the acute hospital for a relapse of Covid-19. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically reasonable or 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis.

You asked the Plan to pre-approve F2 gene analysis and F5 gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that the F2 and F5 genetic tests are not considered to be clinically efficacious; therefore, testing is not medically necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of F2 gene analysis and F5 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140).

You asked the Plan to pre-approve the dental service. You say that you have been seeing this provider since
1987. You say that you would like to continue seeing this dentist. You say that this provider charges less than
the in network dentists that you have tried. You say that you are on a limited income. You also say that this
provider will extend out your payments for services. The Plan denied your request. The Plan says the provider
in this case is out of network. The Plan says that dental services provided 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 that you receive out of
network are not covered. Therefore, we decided that the Plan does not have to pre-approve a limited oral
evaluation (D0140).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance charges for the oxygen concentrator.

You asked the Plan to waive the coinsurance charges for the oxygen concentrator. You say that the Plan's charges do not follow original Medicare guidelines. The Plan denied your request. The Plan says that the correct coinsurance charges were applied.

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 enrollees must pay 15% of the total cost for oxygen and oxygen related equipment. 

We looked at the file and Medicare rules. You have indicated that you rented the oxygen equipment for 36 months prior to the date of service at issue. 

The Plan has not addressed this concern. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The Plan has not provided documentation of your claim history for oxygen equipment rental. The available evidence does not refute that you have rented the oxygen equipment for 36 months. The Plan contracted supplier must continue to provide oxygen equipment and not charge for performing these services. Therefore, we decided that the Plan must waive the coinsurance charges for the oxygen concentrator (E1390).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2020, by an
out-of-network (OON) provider.

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 rendered by an out-of-network provider without prior authorization.

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 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.
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 4,
2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the documentation supports that the enrollee meets criteria for the requested drug, Prolia. Our physician reviewer found the enrollee has osteoporosis and increased fracture risk. The enrollee has a diagnosis of Scleroderma and CREST syndrome with esophageal stricture. The prescriber has indicated that the enrollee would not tolerate zoledronic acid and similar type of drugs. The documentation supports that the Plan's required drug would likely be less effective/and or have adverse effects for the enrollee. Therefore, an exception to step therapy is warranted and the requested drug is recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia.

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.
Sincerely,
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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute inpatient setting for the treatment of respiratory failure secondary to COVID pneumonia. The enrollee's condition is noted to be guarded. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 25, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
laboratory 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 laboratory services provided on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no medical diagnosis for custom shoes.

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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta.
You asked the Plan to pre-approve Tradjenta. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Tradjenta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services (90791) provided June 6, 2019.

You asked the Plan to pay for the mental health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim was filed untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the mental health services was not filed until October 22, 2020. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for mental health services (90791) provided June 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the lower extremity (73700) provided September 27, 2020.You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code billed on the same date of service.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, we have confirmed that code 73700 has a Column I / Column II relationship with code 73701 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the lower extremity (73700) provided September 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant maintenance procedures (D6080).

You asked the Plan to pre-approve the implant maintenance procedures. You say that you need the cleaning for your dental implants. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 implant maintenance procedures (D6080).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (G0297, 76376) provided October 1, 2020.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code G0297 & 76376 is not supported in the medical record. Specifically, neither diagnosis
code billed or the records provided show the enrollee has a smoking history. Because the base service (G0297)
was denied, the additional service (76376) is also non-covered. Based on this information, we decided that
Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan
does not have to pay for radiology services (G0297, 76376) provided October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre 14-day reader for the enrollee.
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says that the conditions needed to approve the device are not indicated.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the monitor considered is therapeutic and the enrollee has a diagnosis of diabetes mellitus. The enrollee has been using insulin multiple times (3 or more) a day. The treatment requires frequent adjustment on the basis of testing results. 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 been met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre 14-day reader for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 27, 2020.

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 August 27, 2020. 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 August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 4 power wheelchair repair (Permobil C-500).

You asked the Plan to pre-approve the wheelchair repair. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover group 4 power wheelchairs.

The Plan must follow Medicare rules. The rules say that a group 4 power wheelchair is not a covered benefit. 

If a wheelchair is not covered by Medicare, repair of that wheelchair also cannot be covered. Based on this information, we decided that Medicare rules for coverage of the wheelchair repair have not been met. Therefore, we decided that the Plan does not have to pre-approve group 4 power wheelchair repair (Permobil C-500).