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

We decided that the Plan does not have to pay an additional amount for the adjunctive pre-diagnostic testing (D0431) provided on March 18, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that you were told that your visit would be $30. You say that you had x-rays done. You say that the lady that cleaned your teeth could not answer any of your questions. You also say that you will no longer be using this dentist. The Plan denied your request. The Plan says adjunctive pre-diagnostic testing 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 adjunctive pre-diagnostic testing is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the adjunctive pre-diagnostic testing (D0431) provided on March 18, 2021.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 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 the patient is a 74-year-old male who was admitted to the current acute care hospital with hemiparesis related to right middle cerebral artery occlusion when thrombectomy was attempted. He was intubated. He has failed only two weaning trials. Additional short-term acute care services are required which can safely be received at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time as transfer would provide a clinical advantage. Transfer may be considered when the patient is more stable and when treatment has completed.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug (A9270) provided in an outpatient setting on April 9, 2021.
You asked the Plan to pay for the self-administered drug. You say that you were not able to administer your own medication when you were not alert. You say that you did not administer any of your own medications as the hospital will not allow you to do so. You also say that all of the medications you took had to be given to you by hospital staff. The Plan denied your request. The Plan says the drug you received are considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug (A9270) provided in an outpatient setting on April 9, 2021.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 22, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that your dentist could not use the prior x-rays because they were poor quality and unreadable. You also say that you do not have the funds to pay this bill. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.
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 code every three years and full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a comprehensive oral evaluation and complete series of intraoral x-rays on January 29, 2019 and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable ceiling lift.
You asked the Plan to pre-approve a patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories (E0639). You say that a ceiling lift is needed in three places in the house. The Plan denied your request. The Plan says the requested lift is identical or similar to the hydraulic lift the enrollee currently has.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a hydraulic lift provided on August 13, 2020. The hydraulic lift provided on August 13, 2020 serves the same purpose as a patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories (E0639). The current lift is still under reasonable useful lifetime. Therefore, we decided that the Plan does not have to pre-approve portable ceiling lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow injections.
You asked the Plan to pre-approve the requested services. You say that the enrollee has constant shoulder pain. The Plan denied your request. The Plan says the service is not a standard of care for pain management of the shoulder.
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 requested services. Our physician reviewer found that in this case, the record indicates the enrollee has arthritis of the shoulder. The requested service is not Food and Drug Administration approved for the requested indication. The requested service is considered experimental and investigational for the requested indication.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), initial periapical x-ray (d0220), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on April 9, 2021.
You asked the Plan to pay for the unspecified preventive service. You say that you called the plan before your appointment. You say that you were advised by a plan representative that this provider was in network. You also say that you should not be responsible for the payment. The Plan denied your request. The Plan says unspecified preventive service 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 unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), initial periapical x-ray (d0220), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on April 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve aide services. You say that you are worried about falling and injuring yourself. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
We looked at the file and Medicare rules. In this case, there are no medical records to show that skilled nursing or therapy services are necessary. Custodial care is not covered. Based on this information, we decided that Medicare rules for coverage of aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you have an open wound that needs to be closed. The Plan denied your request. The Plan says there are in-network providers available.
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 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 wound care services to be provided by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 22, 2020.

You asked the Plan to pay for lab tests. You say that you are requesting payment for this claim. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from March 5, 2021, to March 6, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you stayed overnight in the hospital and did not have access to your regular prescription medicines. You also say that you would like these self-administered drugs to be approved for payment. The Plan denied your request. The Plan says self-administered drugs are not Part B covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from March 5, 2021, to March 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hematopoietic progenitor cell autologous transplant.
You asked the Plan to pre-approve the services. You say that this is medically necessary, as there are no other treatments. The Plan denied your request. The Plan says if the enrollee is positive for TP53 mutation, the treatment would then be chemo-immunotherapy.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have resistant non-Hodgkin's lymphoma, or poor prognostic features after initial response. 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 a hematopoietic progenitor cell autologous transplant.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection 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 the records must show three physical exam tests that were abnormal or resulted in sacroiliac pain.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is documentation on physical examination of tenderness to the SI joint but no mention of SI provocative testing being completed with positive findings. The review has determined that the requested sacroiliac joint injection is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and additional intraoral x-ray provided on February 4, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and additional intraoral x-ray. You say that they didn't do a lot on your teeth and your last dentist did more with no extra charges. You say that what you pay monthly for your Plan should cover most of the cost. The Plan denied your request. The Plan says reimbursement has already been issued for one exam and one intraoral x-ray.
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, you also have a maximum benefit of one comprehensive oral evaluation every three years and one intraoral x-ray every year. The Plan paid for a comprehensive oral evaluation provided on September 3, 2019 and one intraoral x-ray provided on February 4, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and additional intraoral x-ray provided on February 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a laboratory service (88312) and a tissue exam by a pathologist (88304) provided on March 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you receive the specimen, and the test is performed. You also say that the specimen is sent to you by the physician's office. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a laboratory service (88312) and a tissue exam by a pathologist (88304) provided on March 4, 2021, 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 larger battery for a portable oxygen system (E1399).
You asked the Plan to pre-approve the battery. You say that the larger battery is medically necessary. The Plan denied your request. The Plan says payment for all oxygen accessories is bundled in the oxygen renal payment.
The Plan must follow Medicare rules. Medicare rules say that oxygen reimbursement is a bundled payment. All options, supplies and accessories are considered included in the monthly rental payment for oxygen equipment. We looked at the file and Medicare rules. Oxygen accessories cannot be unbundled for payment. All accessories are included in the rental allowance. Based on this information, we decided that Medicare rules for coverage of the battery have not been met. Therefore, we decided that the Plan does not have to pre-approve a larger battery for a portable oxygen system (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 26, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that the bill for these services was paid in full and you would like to be reimbursed. The Plan denied your request. The Plan says if seen by an OON dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in that area. The Plan also says that you are responsible for the difference between the INFS and dentists' charged fees when visiting an OON dentist.

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, you are responsible for a 50% coinsurance for the periodic oral evaluation, bitewing x-rays, and prophylaxis, plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 26, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Apligraf (Q4101).

You asked the Plan to pre-approve Apligraf. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for Apligraf have not been met.

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 Apligraf. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that you have a Wagner Grade 4 diabetic heel ulcer. The record indicates that you have exposed tendon and muscle. The wound has up to 50% eschar, 25% slough and gray granulation tissue. The wound is improving over a thirty-day period. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Apligraf have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Apligraf (Q4101).
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a different 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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.