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

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).

You asked the Plan to pre-approve the dental items. You say that the partial dentures were approved last year. You say that they were denied this year. You also say that a couple of your teeth were bad and had to be pulled out. The Plan denied your request. The Plan says partial dentures 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, partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiology services provided from
November 18, 2020, to January 5, 2021.
You asked the Plan to waive the copayments for the computed tomographies and positron emission
tomography scan. You say that the bill is confusing. The Plan denied your request. The Plan says you were
charged this coinsurance 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 $175
copayment for Outpatient Diagnostic Tests.
You have been asked to pay a $175 copayment for the computed tomographies and positron emission
tomography. The tomographies fall within the Outpatient Diagnostic Tests 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 copayments for the radiology services provided from November 18, 2020, to
January 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve more hours of attendant care services (S5125).

You asked the Plan to pre-approve the attendant care services. You say that you need to get more hours with your caregiver. The Plan denied your request. The Plan says you do not meet the state benefit guidelines for more hours of attendant care services.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the attendant care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve more hours of attendant care services (S5125).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 home health skilled nursing visits.
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 submitted records show that you have wound care needs. The wound is over two years old and needs cleansing, packing, dressing, covering, and wrapping. The records are insufficient to show that prior care is resulting in improvement of the wound. Ongoing skilled nursing visits are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 home health skilled nursing visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225).
You asked the Plan to pre-approve the dental item. You say that you need this space filled in. You also say that you feel that this should be covered. The Plan denied your request. The Plan says partial upper denture with a flexible base is not listed as 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, 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 partial upper denture with a flexible base (D5225).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab and Xgeva for the enrollee.
You asked the Plan to pre-approve Pembrolizumab and Xgeva. You say that these drugs are medically necessary. The Plan denied your request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Pembrolizumab and Xgeva. Our reviewer says that Pembrolizumab and Xgeva are not medically reasonable and necessary for the enrollee. Pembrolizumab and Xgeva are not FDA-approved for the enrollee's diagnosis without PD-L1 status. The use of Pembrolizumab and Xgeva are not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Pembrolizumab and Xgeva.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab and Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab and Xgeva for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second duplex scan provided on March 24, 2021.
You asked the Plan to pay for a second duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no record of a second scan.
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 93971 is not supported in the medical record. Specifically, the record shows one Right Upper Extremity Venous Duplex Exam was performed. Based on this information, we decided that Medicare rules for coverage of a second duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (93971) have not been met. Therefore, we decided that the Plan does not have to pay for a second duplex scan provided on March 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test rendered on March
10, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 each advanced imaging service (e.g. MRI, CT, and PET scans, nuclear medicine, and stress
tests).

Review of the file shows that you received a nuclear stress test on March 10, 2021. You have been asked to pay
a $150 copayment for these services. These services fall within the advanced imaging service (e.g. MRI, CT,
and PET scans, nuclear medicine, and stress tests) benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the nuclear stress test rendered on March 10,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve power wheelchair. You say that the enrollee is a significant risk for skin breakdown and injury due to falls. The Plan denied your request. The Plan says the denial of authorization for this equipment is correct, because this provider is out-of-network with the Plan and this equipment can be obtained from an in-network supplier.
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 a power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that it is very painful to stick your fingers multiple times a day. You say that you check your blood 3 times per day. The Plan denied your request. The Plan says the clinical information does not show that the requested CGM is medically necessary. The Plan says that the enrollee intends to use the requested CGM for monitoring, not for therapeutic reasons.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation form February 2021 indicates that the enrollee is not maintained on insulin therapy. She intends to use a CGM for monitoring, not therapeutic reasons. The enrollee does have diabetes mellitus. The documentation does not show that the enrollee has been using a blood glucose monitor (BGM) and performing testing four or more times a day. The enrollee does not use insulin with three or more daily injection or a Medicare-covered continuous subcutaneous insulin infusion pump. The enrollee's insulin treatment regimen does not require frequent adjustment by the enrollee on the basis of BGM or CGM 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from November 20, 2020, through November 21, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the hospital services provided were medically necessary. The Plan denied your request. The Plan says the enrollee's medical condition stabilized, and subsequent care was not approved.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our reviewer says that the enrollee was stable to transfer as of November 20, 2020 at 9:13AM. Our physician reviewer found the critical care attending physician's note on November 20, 2020, indicates that the enrollee is clinically stable and is cleared for transfer to an in-network facility. The record does not contain any conflicting documentation regarding that recommendation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided after 10 a.m. on November 20, 2020, through November 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from April 1, 2021, through
April 27, 2021.

You asked the Plan to pay for physical therapy. The Plan denied your request. 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 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 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 physical therapy provided from April 1, 2021, through
April 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided March 1, 2021.
You asked the Plan to pay for the emergency visit. You say that the medical records are attached to support the service rendered. Please review and reconsider the claim for payment. The Plan denied your request. The Plan says the records did not support the service provided. The claim was reprocessed and paid based on the level supported by the records: 99284.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 emergency visit Our reviewer says that the records provided do not support 99285 level of service. Our reviewer found the documentation supports a comprehensive exam with 9 organ systems, and medical decision making, presenting problem, acute illness with systemic symptoms, minimal decision making, EKG, and, moderate management options , prescription medications. Therefore, documentation supports level 99284 and 99285 would not be covered. 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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided March 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional home health occupational therapy (OT) visits.
You asked the Plan to pre-approve eight (8) additional home health OT visits. You say that eight (8) additional home health OT visits are medically necessary. The Plan denied your request. The Plan says eight (8) additional occupational therapy (OT) visits are not medically necessary.
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 eight (8) additional home health OT visits. Our reviewer says that additional home health OT is not medically necessary and reasonable. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. The enrollee does not have documented skilled therapy needs. The enrollee's activities of daily living needs appear to be custodial. As such, the requested home health OT services are not shown to be medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional home health OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional home health OT visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment a colonoscopy (45380) provided March 9, 2021.

You asked the Plan to waive the copayment the colonoscopy. You say that the service should be fully covered. The Plan denied your request. The Plan says the colonoscopy was a diagnostic colonoscopy and not a screening test. The correct copayment was applied.

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 $350 copayment for outpatient surgery services. 

You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the outpatient surgery 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 a colonoscopy (45380) provided March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 3.
You asked the Plan to pre-approve the pontic. You say that you need a bridge. The Plan denied your request. The Plan says pontic is not listed as 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, the pontic is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010 x 3).

You asked the Plan to pre-approve the dental services. You say that you feel that implants should be covered. You also say that you need the implants so that you can get dentures. The Plan denied your request. The Plan says implants 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 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 surgical placement of an implant body (D6010 x 3).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on February 25, 2021.