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

We decided that the Plan does not have to pay for the core buildup, including any pins when required, first intraoral periapical x-ray, and crown provided on September 18, 2019.You asked the Plan to pay forthe core buildup, intraoral periapical x-ray, and crown. You say that after your insurance made their payment, your portion of these services should have been $940.00. You also say that you paid $704 for these services.The Plan denied your request. The Plan says you had exceeded the limits set in the subscriber agreement.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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on October 8, 2019 and your annual deductible benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required, first intraoral periapical x-ray, and crown provided on September 18, 2019.Please note, the record shows that the Plan contacted your provider and had them update their accounting to show that you only owe $81 since you have already paid $748.50.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the hips and pelvis.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have received multiple trigger point injections due to pain and muscle spasms. The injections did not provide pain relief and MRIs were ordered due to hip osteoarthritis. There is no documentation of a complaint of hip pain or hip injury. There is no documentation of an exam of your back, hips, or neurological system. There are no basic x-rays or documentation of treatment specifically directed at the hips. The requested MRIs 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 magnetic resonance imaging (MRI) of the hips and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this will allow the enrollee to test more freely. The Plan denied your request. The Plan says that the enrollee is not testing his blood sugar enough or injecting insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day or testing his blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe acute inpatient admission requested on March 5, 2020.You asked the Planto pay forthe inpatient admission. You say that the enrollee requires care at the inpatient level.The Plandenied your request. The Plansaysno acute medical interventions are planned,and the enrollee can receive comfort care in the outpatient observation setting.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the documentation does not support that the rules for inpatient admission have been met. Our physician reviewer found the enrollee is a 90-year-old woman who presented to the hospital on 3/4/20 with shortness of breath.  Theenrollee's pulmonary effort and heart sounds were normal. Laboratory studies were remarkable for elevations of troponin and BNP. A chest X-ray demonstrated possible mild pulmonary edema on a background of chronic interstitial markings. The enrollee was diagnosed with a non-ST elevation MI. BiPAP was administered in the ED. The enrollee was made comfort care due to the family's desires, given her overall poor prognosis and increased risk of mortality. No active treatment was desired. Palliative care was consulted. Medications were ordered as needed for agitation, pain, and shortness of breath. The documentation does not support that inpatient hospital services spanning two midnights were reasonable to expect for the enrollee in this case.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 inpatient admission have not been met.Therefore, we decided that the Plandoes not haveto pay forthe acute inpatient admission requested on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean office visit. You say that you have been seeing this doctor for years. You say that you have to continue these shots or you won't be able to lift your arm.The Plan denied your request. The Plan says there are in-network providers available for these 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 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 withthe 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-approvean office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core buildup, including any pins when required, and crown provided on October 17, 2019.You asked the Plan to pay forthe core buildup and crown. You say that no documents were ever provided to you indicating that a necessary part of the crown procedure would not be covered.The Plan denied your request. The Plan says you were informed prior to the service being rendered that core buildup is nota covered benefit. The Plan also says that the crown was processed according the Plan's negotiated rate.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, core buildup, including any pins when required is not covered under this benefit. The contract also clearly states that you are responsible for 70% coinsurance for crowns received in-network. The Plan is only obligated to pay 30% for crowns provided in-network.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required, and crown provided on October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance angiography (MRA) of the head.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRA is covered when specific criteria are met.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 enrollee is noted to have chronic, intermittent headaches. There is no evidence of associated neurologic signs or symptoms. Recent carotid dopplers andmagnetic resonance imaging (MRI) of the brain showed no significant changes compared to prior imaging. Therefore, the requested MRA of the head is not shown to be medically necessary or 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 these services have not been met.Therefore, we decided that the Plan does nothave to pre-approvemagnetic resonance angiography (MRA) of the head.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ambien.
You asked the Plan to pre-approve Ambien. You say that the enrollee needs to continue taking this medication.
The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's
Part D prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Ambien.
Benefits for Ambien 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist office visit. You say that these services are medically necessary for the member.The Plandenied your request. The Plan says there are in-network providers available for these 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 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 providersavailable 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-approvea specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve28 additional trips for routine transportation.You asked the Plan to pre-approvethe additional trips. The Plan denied your request. The Plan says only 36 one-way trips are covered.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve28 additional trips for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left heart catheterization (93458).You asked the Plan to pre-approve a left heart catheterization (93458). You say that the requested left heart catheterization is medically necessary.The Plan denied your request. The Plan says the requested left heart catheterization is 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 a left heart catheterization (93458). Our reviewer says that the requested left heart catheterization is not medically necessary. Our physician reviewer found the enrollee is with a history of obesity,sleep apnea, hypertension and hyperlipidemia. A clinic note dated 02/03/2020 documents one week of transient chest pain, "position made it better", a normal cardiac physical exam and nonspecific T wave flattening on electrocardiography. An echocardiogram 02/21/2020 reported normal wall motion and normal left ventricular ejection fraction.Based on the records the enrollee has increased coronary risk, very atypical chest pain, a normal cardiac physical exam, mild nonspecific ECG changes and normal regional and global left ventricular systolic function on echocardiography. In this circumstance of atypical symptoms and no objective evidence of ischemia the records do not support the medical necessity for left heart catheterization. Coverage criteria at not met since there are no documented covered indications for the procedure. Current guidelines also do not support left heart catheterization in this 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 a left heart catheterization (93458) have not been met.Therefore, we decided that the Plan does not have to pre-approve a left heart catheterization (93458).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on September 30, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that these services were medically necessary. The
Plan denied your request. The Plan says there are in-network providers available for these services. The Plan
says that no prior authorization was obtained for these 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 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 podiatry services provided on September 30, 2019
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 passive motion exercise device.You asked the Plan to pre-approve the continuous passive motion exercise device. You say that you recently had shoulder surgery and need the device to continue your physical therapy.The Plan denied your request. The Plan says the enrollee does not have supplemental coverage for this device, which goes beyond what Medicare covers.The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery.You have not had total knee replacement surgery.Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFasenra (benralizumab) 30mg/ml.You asked the Plan to pre-approveFasenra. You say that Fasenra is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 Fasenra. Our reviewer says that Fasenra is not medically necessary in this case. Our physician reviewer found the diagnosis appears more likely to be COPD than asthma based on the records. There is no demonstration of bronchodilator responsiveness or normal diffusing capacity, which would favor asthma. The records include no eosinophil count. This needs to be at least 300 to meet coverage criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra have not been met.Therefore, we decided that the Plan does not have to pre-approveFasenra (benralizumab) 30mg/ml.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and bitewings provided on September 10, 2019.You asked the Plan to pay forthe prophylaxis and bitewings. You say that you were not aware that you did not have out-of-network benefits to see an out-of-network dentist.The Plan denied your request. The Plan says the dentist who provided these services is an out-of-network provider. The Plan also says that benefits are only covered when they are received from an in-network provider.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe prophylaxis and bitewings provided on September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intravenous moderate (conscious) sedation/analgesia and endosteal implant provided on May 16, 2019.You asked the Plan to pay forthe intravenous moderate (conscious) sedation/analgesia and endosteal implant. You say that per your cardiologist, you are not to have local anesthesia with epinephrine.The Plan denied your request. The Plan says your plan only covers this service when it is done to prepare the jaw for radiation treatments for cancer (neoplastic cancer disease).Medicare generally does not cover dental services. ThePlan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe intravenous moderate (conscious) sedation/analgesia and endosteal implant provided on May 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRFcare. You say that the enrollee says she will recover better in an intense therapy setting.The Plan denied your request. The Plan says the enrollee does not need 3 hours of therapy a day, or need an intensive team approach for care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's medical conditions appear stable. There are no wound care needs or unaddressed medical issues. He is currently in an outpatient setting and does not require an acute hospital level of care. He is unable to ambulate household distances and requires up to moderate assistance for remaining activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
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 admission is not medically necessary.
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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee had a left knee arthroplasty
on March 2, 2020. He was effectively treated for pain. He received physical and occupational therapy in the
hospital and needs stand-by assist with ambulating 150 feet with a rolling walker. He needs varied assist with
activities of daily living. He has no skilled nursing needs. He has skilled therapy needs but does not require
skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.