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

We decided that the Plan does not have to pay more forthe two additional extractions provided on September 17, 2019.You asked the Plan to pay more forthe additional two extractions. You say that you paid for these services in full. You also say that the coverage booklet says that the plan pays for 2 extractions per year.The Plan denied your request. The Plan says you exceeded the number of allowed extractions for the year.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, extractions are limited to two procedures per calendar year. The record shows that you received four extractions on September 17, 2019, two of which the Plan paid, and your extractions benefit was exhausted. Youmust pay the full cost of the additional two extractions.Therefore, we decided that the Plan does not have to pay more forthe two additional extractions provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe addition of 2 teeth to an existing partial denture (D5650), and the addition of 2 clasps to an existing partial denture (D5660) provided from September 17, 2019 to October 10, 2019.You asked the Plan to reimburse you forthe addition of 2 teeth and 2 clasps to an existing partial denture. You say that  The Plan denied your request. The Plan says the denture adjustments are not listed as covered services.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 denture adjustments are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe addition of 2 teeth to an existing partial denture (D5650), and the addition of 2 clasps to an existing partial denture (D5660) provided from September 17, 2019 to October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued acute care to prevent further complications. The Plan denied your request. The Plan says the same level of care is being provided at the current treatment facility.
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 is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure requiring intubation/ventilation. The enrollee subsequently received a tracheotomy and has since been weaned off of the ventilator. Both the enrollee's intubations and tracheotomy are noted to have been difficult. As such, there are no current plans to decannulate the enrollee. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on April 24, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on April 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement scooter, SpinLife EW-46.You asked the Plan to pre-approve a replacement Group 1 power operated vehicle (K0800). You say thatthe provided scooters are cheap and you are tired of relying on other people to take you shopping etc.The Plan denied your request. The Plan says you received a power scooter on July 9, 2019 and it still meets your in home needs. The scooter you are requesting has convenience and deluxe items for use outside the home.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have scooter. Your scooter serves the same purpose as the replacement Group 1 power operated vehicle requested.Your scooter is still under reasonable useful lifetime. The documentation submitted does not show that the scooter is irreparably worn, irreparably damaged, or that the you had a change in medical condition to warrant a replacement scooter.The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.Therefore, we decided that the Plan does not have to pre-approvea replacement scooter, SpinLife EW-46.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple myocardial positron emission tomography (PET) perfusion studies (78492). You asked the Plan to pre-approve multiple myocardial PET perfusion studies. You say that this is medically necessary. The Plan denied your request. The Plan says a similar test was already performed.
The Plan follows Medicare rules. Medicare rules say that the requested study is covered when medically necessary and the above listed criteria are met. 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 multiple myocardial PET perfusion studies. Our reviewer says that the requested study is not medically necessary at this time. Our physician reviewer found based on the records provided, the enrollee had a reported good quality stress test with no chest discomfort, normal wall motion, normal ejection fraction, attenuation artifact of the inferolateral wall both on rest and stress images and no provokable ischemia. In this circumstance the nuclear stress test report is conclusive with respect to wall motion, ejection fraction and absence of ischemia. The records therefore do not support the medical necessity for nuclear stress testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of multiple myocardial PET perfusion studies have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple myocardial positron emission tomography (PET) perfusion studies (78492).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for hospital services provided on July 24, 2019.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim does not meet Medicare coverage criteria.
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 forward the authorization request or initial denial to substantiate the decision to deny payment. Therefore, we decided that the Plan has to pay for hospital services provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain or ceramic crown on tooth #1 provided on August 27, 2019.
You asked the Plan to pay for the crown. You say that this crown replaced an older crown because your tooth needed a root canal. You also say that both your original dentist and root canal dentist said that you needed a new crown. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, crowns are limited to once every 5 years. The record shows that you received a porcelain or ceramic crown on tooth #1 on March 9, 2016 and your crowns benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the porcelain or ceramic crown on tooth #1 provided on August 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the PT services. You say that you have already received two visits from your provider and would like to continue therapy there. The Plan denied your request. The Plan says you have in-network providers available in your area.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) of the abdomen and pelvis for the enrollee.
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 the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has an abdominal aortic aneurysm (AAA). The AAA was noted as unchanged on an imaging note dated January 8, 2019 as compared to a previous scan on June 3, 2016. There are no active symptoms. The guidelines for an asymptomatic AAA states that surveillance is recommended every 10 years. The requested CTA is not reasonable or medically necessary 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) of the abdomen and pelvis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

e decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) admission.You asked the Planto pre-approvethe SNF admission. You say that the enrollee needs physical therapy and occupational services and you are requesting reconsideration on the denial for SNF admission.The Plan denied your request. The Plan says the enrollee did not meet the medical necessity criteria for coverage of SNF stay.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) admission.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
complications related to recurrent lung cancer. The enrollee is not intubated/ventilated. As LTACHs and ACHs
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.
The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can
then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 8, 2019.You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, the member was inpatient on this date of service. The payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the 30 day supply of \ventricular-assist device (VAD) supplies provided on August 27, 2019 billed with 30 units of code Q0508.
You asked the Plan to pay for the 30-day supply of VAD items. You say that the Plan has approved 360 units of this code for the year and 30 units are billed per month for the monthly supply. The Plan denied your request. The Plan says that based on a CMS rule, only one unit of Q0508 is payable per year.
The Plan must follow Medicare rules. Medicare rules say that the code Q0508 is used to report supplies necessary for the use of a VAD that was placed under Medicare coverage. In this case, the code definition of Q0508 does not include any set amount of time period of supplies. This means that there is no set fee for one unit. In this case, the provider has chosen to bill each unit to equate to one day's worth of supplies billed at 30 units monthly. This was approved in advance by the Plan for the year beginning in July 2019. There is no evidence to support the Plan's rationale that only a single unit is payable per year, which would not be consistent with the continued need for these types of supplies for use with a VAD. Therefore, we decided that the Plan has to pay for the 30 day supply of \ventricular-assist device (VAD) supplies provided on August 27, 2019 billed with 30 units of code Q0508.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on September 6, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that your dentist indicated that your teeth are somewhat loose and recommended having cleanings done four times per year. You also say that this is only the third cleaning. The Plan denied your request. The Plan says this service is not covered under your contract under regular dental benefits. The Plan also says that your contract has limited dental benefits and this service is clearly excluded.
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 periodontal maintenance provided on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a preliminary visit and X-rays to be provided by your chiropractor.You asked the Plan to pre-approve the preliminary visit and X-rays. You say that you would like the Plan to cover these chiropractic services because you have severe back pain, lumbar stenosis and arthritis. The Plan denied your request. The Plan says the Plan only covers manual manipulation of the spine to correct subluxation.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a preliminary visit and X-rays to be provided by your chiropractor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for subsequent nursing facility care provided on August 1, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services for subsequent nursing facility care provided on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel self-injectable mini-cartridges.You asked the Plan to pre-approveEnbrel. You say that other drugs have not been effective for this enrollee.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.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-approveEnbrel self-injectable mini-cartridges.Benefits for Enbrelmay be available under Medicare Part D.Contactthe 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-approve a prefabricated abutment - includes modification and placement (code D6056) and an abutment supported porcelain fused to metal crown (code D6060).
You asked the Plan to pre-approve the prefabricated abutment and abutment supported crown. You say that you are unable to eat normally right now because you can only have a liquid diet. You also say that this has resulted in physical weakness, worsened health, hypertension, and a dramatic increase in your blood sugar. The Plan denied your request. The Plan says these services are 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 a prefabricated abutment - includes modification and placement (code D6056) and an abutment supported porcelain fused to metal crown (code D6060).