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

We decided that the Plan has to pre-approve a crown (D2740) for tooth #30.
You asked the Plan to pre-approve the crown. You say that this treatment is necessary and appropriate for the enrollee. The Plan denied your request. The Plan says that the records do not show that tooth #30 has decay or fracture of more than 50% of the tooth or a broken off cusp.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that a crown restoration (D2740) meets the criteria for coverage. Our physician reviewer found the enrollee's dental record and radiographs indicate the presence of a large restoration exhibiting severe ditching around the margins with probable undermined cusps. This severely weakens the remaining coronal structure. Our reviewer also found that a crown restoration is reasonable and necessary to restore the tooth to normal function and prevent imminent cuspal fractures. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth #30.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there is no evidence that you require services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing LTC 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80307, 82542, 84228, G0480) provided on October 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you did not know prior authorization was needed. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. Prior authorization was not obtained. The service was not urgent or emergent.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (80307, 82542, 84228, G0480) provided on October 27, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 dental extractions and full mouth debridement
services.
You asked the Plan to pre-approve the dental extractions and full mouth debridement services. You say that
your teeth are making you sick and you need to take them out in order to obtain partial dentures. You say that
you are also having trouble eating. You say that every time you eat you get an infection and your gums swell.
The Plan denied your request. The Plan says your benefit for extractions has been exhausted. The Plan says that
full mouth debridement is not a covered benefit under your contract.
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 full mouth debridement services in
dispute are not among those covered. The Plan's benefits do include coverage for dental extractions, but those
benefits are limited to 2 procedure codes per calendar year. The records show that the Plan approved coverage
for 2 dental extraction procedure codes on February 24, 2021. This exhausted your benefit for dental
extractions in the 2021 calendar year. Therefore, we decided that the Plan does not have to pre-approve 14
dental extractions and full mouth debridement services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement insulin pump.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your
request. The Plan says needs can be met with the current insulin pump.
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 pump. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you have insulin dependent diabetes and use an insulin pump that is less than five years old. The current
pump is under warranty and the battery needs to be charged weekly. You prefer a pump that communicates
with the glucose monitor. The request is for a replacement insulin pump. The device is under warranty and the
documentation does not indicate that attempts to address the issue through the warranty have been made.
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 pump have not been met. Therefore, we decided that the Plan does not have
to pre-approve a replacement insulin pump.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee's clinical condition does not require daily skilled services as an inpatient in a SNF.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the exercise equipment purchased on August 10, 2020.
You asked the Plan to reimburse you for these services. You say that the services should be covered. The Plan denied your request. The Plan says the equipment was purchased prior to October 1, 2020.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses up to $300 per calendar year towards covered Wellness Allowance services and exercise equipment purchased from October 1, 2020 to December 31, 2020. The Plan's rules for reimbursement have not been met because the file shows that the exercise equipment was purchased on August 10, 2020. Therefore, we decided that the Plan does not have to reimburse you for the exercise equipment purchased on August 10, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on February 7, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you believed the cost would be $0 unless polyps were removed. You say that the charge is incorrect. The Plan denied your request. The Plan says that the copayment applied correctly.
The Plan must follow Medicare rules. Medicare covers 1 screening colonoscopy every 2 years or 1 barium enema every 2 years for people with high risk of colon cancer. An individual with a person history of adenomatous polyps meets the definition of "person with high risk of colon cancer" under Medicare rules.
There is no evidence that this colonoscopy was ordered for diagnostic purposes or that any polyps were removed during this colonoscopy. The procedure findings submitted shows no polyps were removed and results were normal.
A person with a personal history of polyps is considered to be at high risk of colon cancer. People at a high risk of colon cancer are eligible for screening colonoscopies under Medicare rules and these screening colonoscopies are covered at a greater frequency for those at high risk. No evidence has been submitted to show that your screening colonoscopy benefit was exhausted on this date of service. Based on the documentation submitted by the health plan, we find that you received a screening colonoscopy.
Medicare rules say that, if a preventive service is covered with $0 cost-sharing under Original Medicare, the health plan cannot impose cost-sharing for the service when it is provided by in-network providers. The Provider must follow this rule.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that there is no coinsurance, copayment or deductible for a Medicare-covered colorectal cancer screening exam. The Plan says you must pay a $200 copayment for the colonoscopy. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the colonoscopy. The records show that the colonoscopy was not ordered for diagnostic purposes and no polyps were removed. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy provided on February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora transcutaneous electrical nerve stimulation (tens) device (E0730) provided on July 10, 2019.You asked the Plan to waive the coinsurance fora transcutaneous electrical nerve stimulation (tens) device. You say that you did not want the TENS unit and weretold that you would have no charge. You feel you should not be responsible for the cost share.The Plan denied your request. The Plan says durable medical equipment (DME) has a 20% coinsurance.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 20% coinsurance for durable medical equipment (DME). You have been asked to pay a 20% coinsurance for a transcutaneous electrical nerve stimulation (tens) device. This service falls within the durable medical equipment (DME) benefit category. The total charge minus your network savingsis your 20% coinsurance ($720-$665.90 = $54.10). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora transcutaneous electrical nerve stimulation (tens) device (E0730) provided  on July 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (CPT Code 72197). You asked the Plan to pre-approve the MRI. You say that you are in so much pain that cannot be alleviated by pain medications. The Plan denied your request. The Plan says the services are not necessary. The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found although it is reasonable to consider repeating the MRI which didn't describe the areas in question, and reasonable to avoid the same facility where it was last completed, however, other facilities were provided as options. There was no indication from the notes that this patient would not be able to complete the MRI at one of the alternative locations provided by the Plan. Therefore, this request for MRI pelvis will be considered not medically necessary as submitted.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvethe MRI, pelvis; without contrast material(s), followed by contrast material(s) and further sequences (CPT Code 72197).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coflex device surgery (a metal device placed in between the bones of the lower back) (22867 and 22868).
You asked the Plan to pre-approve coflex device surgery. You say that the items are medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 coflex device surgery. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of spinal instability in this case and that hardware is not needed to stabilize the spine. Also, the Coflex device remains experimental for use in spine surgery. More quality outcomes data is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of coflex device surgery have not been met. Specifically, there is not enough information to determine the safety and efficacy of this item for the member's diagnosis. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve coflex device surgery (a metal device placed in between the bones of the lower back) (22867 and 22868).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on November 12, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says services from an out-of-network provider are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers supplemental dental benefits from a network provider only.
We looked at the file and the Plan's rules. The file shows that you received services from a provider that was not part of the Plan's network. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home services provided on November 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for rest home services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for rest home services provided on November 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 29, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says there is no evidence the prescribing physician saw the enrollee.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed in the Medicare rules section. 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 lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 29, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve continued treatment with Keytruda solution 100mg/4ml 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 that medical studies have not proven that this drug duration is safe and helpful for treatment of the health problem.

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 services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found per the package insert, treatment should be continued until progression, toxicity, or more than 24 months. That "or" preposition allows approval until progression.

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 been met. Therefore, we decided that the Plan has to pre-approve continued treatment with Keytruda solution 100mg/4ml for 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says there are in-network options available to provide the requested services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the physician's services to be provided by the out-of-network provider.