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

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 21, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services provided to the enrollee on March 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bridge.You asked the Plan to pre-approvethe dental service. You say that you had 2 teeth pulled and you need a bridge to replacethem. You say that you are allowed $2,500 for crowns. You say that bridges are just crowns that are connected. You say that this should allow you to get a bridge.The Plan denied your request. The Plan says bridges are not 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, a dental bridge is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a dental bridge.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a flu shot provided on September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a flu shot. You say that you have had this service the last two years and you always had them covered. You say that this shot should be included as well. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available to provide these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 a flu shot provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the ER visit, and inpatient admission and services provided from June 24, 2019 to June 30, 2019.
You asked the Plan to pay for the ER visit and inpatient admission and services. You say that you made the decision to take the enrollee off of hospice care. You also say that the enrollee was in a lot of pain and taken to the ER. The Plan denied your request. The Plan says that the enrollee was discharged from hospice due to the ER visit and inpatient admission. The Plan also says that, according to the Medicare Claims Processing Manual, Chapter 11, section, 30.4: hospice election may be revoked at any time but claims will continue to be paid fee-for-service (original Medicare) as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable hospice election form for this case. Therefore, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the ER visit, and inpatient admission and services provided from June 24, 2019 to June 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.You asked the Plan to pre-approve the complete maxillary denture. You say that the enrollee states that he lost his previous upper denture. You also say the enrollee said the Plan said that if you sent in an appeal, a new upper complete may possibly be covered.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, complete dentures are limited to one procedure every five plan years. The record shows that you received a complete maxillary denture on March 17, 2017 and your complete denture benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the EMS services were medically necessary for you. You say that they came to your house and stabilized you after you had fainted. You say that you later did end up in the emergency room after fainting again. You stated that the EMS provided a vital service in your recovery and should be covered.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 October 23, 2019. 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 forthe ambulance services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea removal of an impacted tooth (D7220).You asked the Plan to pre-approvethe dental service. You say that you need the extraction done. You say that you need this to be done in order to move forward with the partial denture.The Plan denied your request. The Plan says simple extractions are covered, not surgical extractions.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 removal ofan impacted tooth is among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea removal of an impacted tooth (D7220).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient office visit (99212) federally qualified health center visit (G0467) and foot exam 3 components (G9226) provided August 28, 2019.You asked the Plan to pay forthe office visit. You say that you are resubmitting the claim  and supporting documents with patient encountered for chronic pain follow-up and physician performed evaluation and management service.The Plan denied your request. The Plan says the claim service lacks information or has submission/billing errors which is needed for adjudication.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient office visit (99212) federally qualified health center visit (G0467) and foot exam 3 components (G9226) provided August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial denture.You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says this service is not a covered benefit under your supplemental dental 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 maxillary partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora hepatitis A and hepatitis B vaccine (90636), typhoid vaccine (90691) and their administration (90471) provided on August 19, 2019 through September 23, 2019.You asked the Plan to pay for the immunizations. You say that you received these immunizations due to a health risk of foreign travel and believe they are covered by Medicare. The Plan denied your request. The Plan says the services in question are not covered under your contract under any normal circumstances. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the immunizations. Therefore, we decided that the Plan does not have to pay for a hepatitis A and hepatitis B vaccine (90636), typhoid vaccine (90691) and their administration (90471) provided on August 19, 2019 through September 23, 2019. Benefits for the immunizations 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 pre-approvea custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).You asked the Plan to pre-approvethe custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that this enrollee has done the first part of the implant service last year. You also say that after the implant body was placed, they had to wait three to four months to continue.The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 thiscase.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-approvea custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea blood pressure monitor (E1399).You asked the Plan to pre-approvea blood pressure monitor. You say that you suffer from hypertension which requires you to have readings on a daily basis before taking blood pressure medication.The Plan denied your request. The Plan says a blood pressure monitor is a non-covered benefit by Medicare and your health plan.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis.Records show that you are not on home dialysis. Although a home blood pressure monitor may be appropriate for you in this case, neither Medicare nor the Plan provides coverage of this item for your condition.Therefore, we decided that the Plan does not have to pre-approvea blood pressure monitor (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2751), core build up (D2950), and a root canal (D3320).You asked the Plan to pre-approvethe dental services. You say that you have requested authorization for these services many times with different providers. You also say that the services keep getting denied.The Plan denied your request. The Plan says the dental servicesyou requested are not listed as 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 offersa dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea crown (D2751), core build up (D2950), and a root canal (D3320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for enrollee.You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 24, 2020 with acute respiratory failure. She does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. All medically necessary services are being provided in the current acute care setting. 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 necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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 for enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided by Out of Network (OON) provider, on November 27, 2019.You asked the Plan to waive the coinsurance for DME and related supplies. You say that you have not been charged in the past and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. You received DME and related supplies on November 27, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see chart below. Date of ServiceServiceAllowed AmountAmount You Owe11/27/2019E0601$64.12$12.8211/27/2019E0562$172.90$34.5811/27/2019A4604$47.93$9.59The total amount you owe is: $56.99.You have been asked to pay the total coinsurance amount of $56.99 for DME and related supplies. DME and related supplies fallwithin the DME and related supplies 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 coinsurance for DME and related supplies provided by Out of Network (OON) provider, on November 27, 2019.
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 SNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that it is not reasonable or necessary to receive inpatient SNF level therapy for a member who is functioning at their physical baseline.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your 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-approveskilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on September 21, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you cannot afford to pay.The Plan denied your request. The Plan says the copayment applied 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 $150 copayment for Medicare-covered one-way ground ambulance benefit.You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport 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 forthe ambulance transport provided on September 21, 2019.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Lucentis
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the step therapy requirement is not met.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema in the left eye. She has been receiving Lucentis since 2018. She has not tried and failed the plan's required drug, Avastin; however, step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. The enrollee has been receiving Lucentis since 2018; therefore, step therapy does not apply. The Lucentis is reasonable and medically necessary for the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Lucentis
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (POV) (K0800).You asked the Plan to pre-approve a group 1 power operated vehicle (POV) (K0800). You say that the requested POV is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested POV.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 1 power operated vehicle (POV) (K0800). Our reviewer says that the enrollee does not meet criteria for the requested POV. Our physician reviewer found the enrollee has left hip avascular necrosis (AVN). As per a 2/5/2020 report, the enrollee is noted to be taking oral steroids, muscle relaxants, and opiates. He has hip pain, but the exam reveals no focal deficits. Ambulation is assisted by rolling walker use. The enrollee has AVN, causing mobility and activities of daily living deficits. The records note the enrollee is ambulatory and uses a rolling walker. A lesser device can assist this enrollee. A POV is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 1 power operated vehicle (POV) (K0800) have not been met.Therefore, we decided that the Plan does not have to pre-approve a group 1 power operated vehicle (POV) (K0800).