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

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) provided on August 15, 2019.
You asked the Plan to pay for the dental services. You say that you had another denied claim earlier this year which was paid on appeal. The Plan denied your request. The Plan says you dental rider was not effective on this date and you have no routine dental benefits. The plan states they reviewed your claim history and verified that date of service February 14, 2019 was overturned in case ST004230CT as a onetime exception for the same provider. The Plan states you were advised of your dental benefits and option to add dental rider for dental benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your dental rider was not effective on this date and you have no routine dental benefits. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0676).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0676).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out-of-network provider at the in-network 
You asked the Plan to pre-approve these services. You say that the enrollee cannot afford the out-of-network coinsurance. The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 40% coinsurance for out-of-network outpatient mental health care.
You are not a network provider with the plan. If the enrollee chooses to receive services from an out-of-network provider, they will be asked to pay a 40% coinsurance for these services. These services fall within the out-of-network outpatient mental health care benefit category. This means that the enrollee will be asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. The Plan has network providers from which the enrollee may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve services with an out-of-network provider at the in-network rate
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that IRF care would be the best treatment option.The Plan denied your request. The Plan says the enrollee is medically stable and does not require frequent physician oversight of the rehab program.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted on 3/25 after a fall and was discharged on 3/27. He is currently at home receiving home health services. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. The patient may benefit from PT and OT but the documentation does not indicate that the patient requires this on an intensive level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled nursing needs shown.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested skilled nursing services do not meet the definition of home health aide services as per Section 50.2 as the services are not reasonable and necessary to the treatment of the enrollee's illness or injury. The enrollee does not have ongoing skilled nursing needs. There is no evidence of new enteral feedings, IV medications, complex wound care. The enrollee has had extensive prior skilled nursing visits and has had extensive education on disease and medication management therefore additional skilled nursing visits are not medically necessary by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of tildrakizumab (Ilumya).
You asked the Plan to pre-approve tildrakizumab. You say that this drug is approved and effective for the enrollee's condition, and the enrollee is not a good candidate for alternative treatments. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee has not tried, failed, or had a contraindication to any of the conventional therapies to treat the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 tildrakizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for use of tildrakizumab. Our physician reviewer found the Plan requires that the enrollee has tried at least one of the following treatments for at least 3 months for the enrollee's condition: oral therapy (such as Methotrexate, Cyclosporine, or Acitretin), oral Methoxsalen plus ultraviolet A light, or the enrollee has tried one biologic disease-modifying antirheumatic drugs (DMARD), or the enrollee has a contraindication to these treatments. The clinical information provided indicates that there has been no trial, failure, or contraindication noted to any of the conventional therapies to treat the enrollee's condition. Therefore, the documentation does not support that tildrakizumab is medically reasonable and 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 tildrakizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of tildrakizumab (Ilumya).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 29, 2017.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on September 29, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inogen G5 compressor and portable oxygen (CPT Code 99213) to be provided by a non-contracted provider.
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment (DME) have not been met. Based on a review of the additional information received, it was determined that the request for coverage of an Inogen G5 compressor and portable oxygen to be rendered by a non-contracted provider is not covered by Medicare nor is it offered as a supplemental benefit by the Plan. The rules say that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is not covered. Therefore, we decided that the Plan does not have to pre-approve Inogen G5 compressor and portable oxygen (CPT Code 99213) to be provided by a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home blood pressure monitor purchased on August 29, 2019.You asked the Plan to pay forhome blood pressure monitor. You say that you had called about coverage for the blood pressure monitor and you were told it was covered. You also asked if you can go to a pharmacy to obtain and you were told yes.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pay forhome blood pressure monitor purchased on August 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an arthroplasty (27447) and pay for self-administered drugs provided on September 24, 2019.
You asked the Plan to waive the coinsurance for an arthroplasty and pay for self-administered drugs. You say that you were told you would be inpatient for this service. The Plan denied your request. The Plan says this was an outpatient surgery.
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 25%
coinsurance for outpatient surgery in an outpatient hospital. The rules also say that Medicare Part B generally does not pay for self-administered drugs. You have been asked to pay a 25% coinsurance for an arthroplasty. The record does not show that this service was provided during an inpatient stay, so an arthroplasty falls within the outpatient surgery in an outpatient hospital 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. Furthermore, 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 waive the coinsurance for an arthroplasty (27447) and pay for self-administered drugs provided on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 6, 2019 to August 27, 2019.You asked the Plan to pay forthe acute inpatient level of care. You say that there is no basis for the denial of inpatient services. As reflected in the medical record, this member's care was medically justified as inpatient.The Plan denied your request. The Plan says the inpatient admission was not authorized and the inpatient stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting. 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 acute inpatient level of care. Our reviewer says that this enrollee did not meet the medical necessity criteria for inpatient services Our physician reviewer found the enrollee had stable vital signs and no physical complaints. The admitting provider noted there were no concerns for infection or metabolic disturbances. Plan of care included a psychiatric consultation, medication for agitation as needed, and continuation of home medications. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. Documentation repeatedly notes discharge was hindered by limitations of a disposition location.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 acute inpatient level of care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 6, 2019 to August 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were out walking when you began to feel very ill. You say that you felt nauseous and close to fainting so you sat down. Someone called 911 and local paramedics came to help you. You say that you were carried to their vehicle where you were evaluated and treated. After cooling down, you say that you became less symptomatic and felt okay. The paramedics wanted to take you to the hospital however you declined. You say that even though you weren't transported, you were evaluated and treated by medical professionals and you believe that the Plan should cover the charges. 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 6, 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 for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services on September 9, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for observation services. You say that you went to the emergency room and were admitted for kidney stones. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation services on September 9, 2019 provided by an in-network provider. You are asked to pay a $275 copayment for in-network observation services. 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 observation services on September 9, 2019 provided by an in-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for in-home assistance provided by a family member.You asked the Plan to pre-approve coverage for the in-home assistance provided by a family member. You say that your daughter has had to move in to help you due to your medical condition.The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that charges imposed by immediate relatives are not eligible for payment. Although the in-home assistance from your daughter may be appropriate, Medicare payment cannot be made for this service.Therefore, we decided that the Plan does not have to pre-approve coverage for in-home assistance provided by your family member.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo core buildups, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildups. You say that there is clear evidence of open margins compromising tooth cuspil integrity causing hyper sensitivity for the enrollee.The Plan denied your request. The Plan says that Medicare does not cover this service and therefore this service is not covered by thePlan.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-approvetwo core buildups, including any pins when required (D2950).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide additional physical therapy visits (97164).
You asked the Plan to provide the physical therapy visits. You say that more physical therapy is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 provide the physical therapy visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or under the supervision of a therapist. The requested services
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified
therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition
or to prevent or slow further deterioration.
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 physical therapy visits have not been met. Therefore, we decided that the
Plan does not have to provide additional physical therapy visits (97164).