Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve inpatient mental health services. You say that the requested services are needed. The Plan denied your request. The Plan says rules for pre-approval have not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that, based upon review, the records provided for the admission of the enrollee do not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to themselves or others, no auditory or visual hallucinations. The enrollee was noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from May 19, 2020, through August 10, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says HCPCS code S9328 has a status code of I, which is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that HCPCS/CPT codes with a status indicator of I are not recognized by Medicare and will not be paid. Medicare uses another code for reporting of, and payment for, these services. 

We find that CPT code S9328 is not supported in the medical record. Specifically, S9328 has a status indicator of I and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare. 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 pay for the home infusion therapy services (S9328) provided from May 19, 2020, through August 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no skilled nursing services are identified. While the member requires skilled therapy services, they do not require them on a daily basis. Finally, the member does not require these services on an inpatient basis 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital on November 3, 2020.

You asked the Plan to waive the copayment for lab work. You say that you believe this is double billing. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient diagnostic tests/in-network/laboratory tests/outpatient hospital. 

You have been asked to pay a $40 copayment for lab work. The correct copayment has been applied to the lab work that was provided in an outpatient hospital setting. Lab work falls within the outpatient diagnostic tests/in-network/laboratory tests/outpatient hospital 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 lab work provided by a participating hospital on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a free-standing toilet safety frame.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily used for a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a free-standing toilet safety frame.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for acupuncture.

You asked the Plan to pre-approve the referral. You say that this should be covered. The Plan denied your request. The Plan says the services are available in-plna.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for acupuncture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for injection procedure. You say that you are appealing the Plan's denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 the medical services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the grocery delivery program.

You asked the Plan to pre-approve the grocery delivery program. You say that you would like reconsideration because you received the informational card past the registration date. The Plan denied your request. The Plan says you called to register after the registration period had ended.

Medicare generally does not cover grocery delivery services. However, the Plan offered a supplemental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and Plan rules. Based on this information, we decided that rules for coverage of the grocery delivery program have not been met. Specifically, registration for this service was open until December 9, 2020. The record indicates that you requested authorization past this date. Therefore, we decided that the Plan does not have to pre-approve the grocery delivery program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6057, D6010) 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 this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D6057, D6010) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of the torus mandibularis (D7473).

You asked the Plan to pre-approve the dental service. You say that you have difficulty chewing food as you have almost no teeth. You say that you cannot fit any dental prosthesis due to the additional bones in the roof of your mouth. You say that you need this procedures done so you can improve your quality of life and complete nutritional satisfaction. The Plan denied your request. The Plan says removal of torus mandibularis is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of the torus mandibularis (D7473).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 SNF care. 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. Daily skilled services are not shown to be 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 fillings provided on September 15, 2020.

You asked the Plan to pay for the dental services. You say that you had several fillings restored. You say that the teeth were damaged due to chemotherapy. You say that the dentist repaired them so that you would not lose the teeth. You say that you are on a very tight budget and cannot afford to pay the $155 copayment. The Plan denied your request. The Plan says there is an allowance of $2,000 for covered dental services. The Plan says that the allowance has been exhausted.

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 $2,000 annual allowance has been exhausted.

The Evidence of Coverage clearly states that you pay 100% of charges beyond the $2,000 allowance. Therefore, we decided that the Plan does not have to pay for the 3 fillings provided on September 15, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is currently receiving appropriate care.

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 enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee's long-term prognosis is unclear. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve advanced foot prosthesis, flex-walk system or equal (L5981).

You asked the Plan to pre-approve advanced foot prosthesis. You say that you have met criteria for the prosthetic required. The Plan denied your request. The Plan says the prosthetic requested exceeds your needs.

The Plan follows Medicare rules. Medicare rules say that for the flex-walk system or equal, the enrollee must have a functional level of 3 or 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 advanced foot prosthesis. Our reviewer says that this service is not medically necessary and reasonable. Our physician reviewer found medical records do not document you as a functional K3 ambulator which is required for the prosthetic you are requesting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of advanced foot prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve advanced foot prosthesis, flex-walk system or equal (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) oral/facial photographic images (D0350) intraoral-complete series x-ray (D0210) provided September 9, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the dental services. The Plan denied your request. The Plan says these services are not covered under the plan benefits or exceeds the benefit frequency limitation.
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. Comprehensive oral exams is covered once every 3 years and complete series x-ray is covered once every 5 years. The records show that these services were already reimbursed for date of service January 30, 2020. Oral/facial photographic images is not covered under the plan benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive oral exam (D0150) oral/facial photographic images (D0350) intraoral-complete series x-ray (D0210) provided September 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pomalyst capsules.
You asked the Plan to pre-approve Pomalyst capsules. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 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 pre-approve Pomalyst capsules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary.

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 100 additional non-ambulance, one-way transportation trips.

You asked the Plan to provide additional non-ambulance transportation. You say that you have no other access to transportation and need this service to get to your appointments. The Plan denied your request. The Plan says this benefit has been exhausted, and no additional trips can be provided.

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 30 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 100 additional non-ambulance, one-way transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex Superion device. You say that the Vertiflex Superion device is medically necessary. The Plan denied your request. The Plan says the Vertiflex Superion device is 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. Experimental services and devices 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 Vertiflex Superion device. Our reviewer says that the spacer is experimental. More research is needed to show safety and efficacy of the device; therefore, it is not currently covered by Medicare. 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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150).

You asked the Plan to pay for the dental service. You say that you have not had any dental services for more than 2 years. You also say that your plan must have you confused with someone else. The Plan denied your request. The Plan says 1 comprehensive oral exam every 36 months. The Plan also says that the frequency limit for this service has 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, the frequency limit for this service has been exceeded. The record shows that the Plan paid for a comprehensive oral exam that you received, less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150).