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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not happy with your previous dentist, and found a new dentist who provided this service. 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150), and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips.

You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your request. The Plan says this brand is not covered by the plan.

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 the strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there is not any specific medical reason for the enrollee to receive the requested brand over the plan's preferred brands.

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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services.

You asked the Plan to waive the copayments for laboratory services. You say that you 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 a $10 copayment for laboratory services.

You received laboratory services. Therefore, you are responsible to pay a $10 copayment per each laboratory service. The total amount you owe is: $10 (copayment) x 2 (laboratory services) = $20.

You have been asked to pay the total copayment amount of $20 for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 copayments for laboratory services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) stay.

You asked the Plan to pre-approve the SNF stay. You say that you are depressed and cannot go home alone, and that you do not have room for home health services in your home. The Plan denied your request. The Plan says you have received treatment at an inpatient rehab facility and have progressed toward your short term and long-term goals and that your continued rehabilitation needs can be met at a lower level of care.

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 stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not have complex wound care or other skilled nursing needs that requires a SNF stay. The patient's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter 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 stay have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) stay.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for dental services (D0140, D2740, D0220) provided to the enrollee.

You asked the Plan to pay for the services. You say that the claims should be reprocessed for payment. The Plan denied your request. The Plan says that payment is not allowed for the claims, because they were submitted without a diagnosis.

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 has not substantiated their denial in this case. There is no requirement for a diagnosis for dental services listed anywhere in the Evidence of Coverage. The plan did not provide any medical records or x-rays to determine if the services were medically necessary. There is no evidence that x-rays or records were requested in this case. Therefore, we decided that the Plan has to pay for dental services (D0140, D2740, D0220) provided to the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that this service is medically necessary. The Plan denied your request. The Plan says the criteria for the requested service are not met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a metabolic brain PET scan.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found at the present time
Medicare (per the applicable NCD) only covers a PET/CT of the brain for evaluation of patients who meet
diagnostic criteria for both frontotemporal dementia (FTD) and Alzheimer's disease (AD) (when additional
requirements for coverage are met). In this case you are only said to have an MCI (stable since 2019). You are
not indicated of having either let alone both AD and FTD.

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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a metabolic brain PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care.

You asked the Plan to waive the copayment for inpatient care. You say that you believed the copayment would be waived. The Plan denied your request. The Plan says this processed 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 $345 copayment for each day for the first 5 days of each inpatient hospital stay.

You have been asked to pay a $1,725 copayment for the first five days of your inpatient care ($345 x 5 days = $1,725). 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 inpatient care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that the charges are too high for the service you received and you 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 a $490 copayment for days 1-4 for inpatient hospital care.

You had an inpatient hospital stay. Therefore, you are responsible to pay a $490 copayment for days 1-4. $490 (copayment) x 4 (inpatient days) = $1,960.

You have been asked to pay the total copayment amount of $1,960 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for this condition.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device remains experimental for use in spinal surgery. More research is needed to show safety and effiacy of the device. There is no spinal instability. The hardware is not needed. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter procedure.

You asked the Plan to pay for insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older, (36556). You say that the procedure was done twice. The Plan denied your request. The Plan says one claim was paid and the second claim is a duplicate.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, there is no modifier on the claim. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the catheter procedure.
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 the
enrollee.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
enrollee. The Plan denied your request. The Plan says LTACH criteria are not met, and the enrollee's medical
needs are being met in the current acute care setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the 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 the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.

You asked the Plan to pre-approve a power mobility device. You say that a power mobility device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan follows Medicare rules. Medicare rules say that a power mobility device will not be covered if the patient does not have mobility deficit that impairs their participation in daily activities inside the home, 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 device.

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 power mobility device. Our reviewer says that based on the medical records provided there is no documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living. Based on the medical records provided there is no documentation that you have tried and failed a walker or manual wheelchair in the home. There is no indication you can safely operate a power mobility device inside the home. Medicare coverage criteria are not met.

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 power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services.

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 $65 copayment per visit for Medicare-covered urgently needed services.

Review of the file shows that you received urgent care services. Per the contract with the Plan, there is a $65 copayment per visit for Medicare-covered urgently needed services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $51.38. Given that the allowed amount was less than the $65 copayment, you have been asked to pay $51.38 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the urgent care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician evaluation and management
service (99214).

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the
service provided.

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 $45 for
each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.

You have been asked to pay $45 for the Medicare-covered exam provided. The contract states that enrollees
must pay $45 for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. The
medical record provided for this visit indicates that the exam was performed to diagnose and treat conditions of
the eye. 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 physician evaluation and management
service (99214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not a covered benefit for this condition.

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 the injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this is an experimental/ investigational procedure. Therefore, it is deemed not medically
reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve platelet-rich plasma injections for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this drug is not being prescribed for a medically accepted indication.

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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation
indicates that the enrollee has anemia with various causes to include iron deficiency, B12/folate deficiency, and
newly diagnosed MDS. Iron stores have recently been replenished. The review has determined that the
documentation does not support that the Retacrit is medically reasonable and necessary for the enrollee. The
documentation does not support that the Retacrit is safe and effective for the enrollee.

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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit for the enrollee.