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

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, such as skilled nursing facility, home with home health services, or home with outpatient therapy.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 reviewer says that the requested IRF care is not considered medically reasonable andnecessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. Functionally given her current low endurance for activity will not tolerate IRF level of therapies. The enrollee may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current fatigue level.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate maxillary denture (D5130), removable prosthodontic procedure (D5899), and two extractions (D7140 x2) provided on October 9, 2019.
You asked the Plan to pay for the immediate maxillary denture, removable prosthodontic procedure, and extractions. You say that the Plan documentation says the procedure requested was covered at 50%. You also say that you were unaware that you needed a pre-determination for these services. The Plan denied your request. The Plan says immediate maxillary denture and removable prosthodontic procedure are not covered services under your plan benefits. The Plan also says that the extractions exceeded the maximum benefit allowed.
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, immediate maxillary denture (D5130) is not among those covered under this benefit. The contract also clearly states that extractions are limited to one simple extraction every year. The record shows that you received an extraction on August 19, 2019 and your extractions benefit had been exhausted. The record shows that the Plan reviewed your call history, which shows the provider's office contacted the Plan for information on September 4, 2019. The Plan advised that only listed codes on the Summary of Benefits are covered by the Plan, and faxed a copy of the summary to the provider's office. Therefore, we decided that the Plan does not have to pay for the immediate maxillary denture (D5130), removable prosthodontic procedure (D5899), and two extractions (D7140 x2) provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam, problem focused (D0140) provided March 20, 2020.
You asked the Plan to pay for the dental services. You say that you were referred from one dentist to another dentist office who felt this provider could better serve your needs. The Plan denied your request. The Plan says services are not covered when provided by an out of 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. The health plan contract specifically says that dental services must be performed by a participating general dentist. 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 limited oral exam, problem focused (D0140) provided March 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like these services until you feel comfortable going home. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You are medically stable with no evidence of need for supervision by physical medicine and rehab Physician or acute rehab nursing care needs. You may benefit from further physical therapy and an occupational therapy but do not require an intensive therapy program. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services (99190) have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean ankle foot orthosis and addition.You asked the Plan to pre-approveAnkle foot orthosis, plastic with ankle joint, custom fabricated (L1970), and Addition tolower extremity, lacer molded to patient model, for custom fabricated orthosis only (L2330). You say that the enrollee continues to have pain with ambulation and the requested brace is part of the treatment plan.The Plan denied your request. The Plansays Medicare criteria are not 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 Ankle foot orthosis,(AFO)plastic with ankle joint, custom fabricated (L1970), and Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only (L2330). Our reviewer says that the requested itemsare not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided the health plan's denial should be upheld. The enrollee is noted to complain of bilateral ankle pain and weakness.  Prior evaluation has revealed S1 radiculopathy. There is no evidence that the enrollee has instability of the ankles. The enrollee is noted to walk with a normal gait. The treatment plan was to continue wearing braces that were previously dispensed to the enrollee on October 4, 2019. There is no evidence to support that AFOs are necessary or that the enrollee's current AFOs need to be replaced. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ankle foot orthosis, plastic with ankle joint, custom fabricated (L1970), and Addition to lower extremity, lacer molded to patient model, for custom fabricatedorthosis only (L2330) have not been met.Therefore, we decided that the Plan does not have to pre-approvean ankle foot orthosis and addition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two reconstructions of the jaw for endosteal implants.
You asked the Plan to pre-approve the reconstructions of the jaw for endosteal implants. You say that the enrollee needs custom prosthetics to restore her occlusion. The Plan denied your request. The Plan says this service is 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. Though the Plan offers a dental benefit in excess of Medicare coverage, this service cannot be covered by Medicare since it is a service for the replacement of teeth, meaning that it falls into the category of excluded dental services. Further, the Plan offers an extra benefit which also does not cover implants. Therefore, we decided that the Plan does not have to pre-approve two reconstructions of the jaw for endosteal implants.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on January 31, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that per hospice, this enrollee was discharged on January 30, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 30, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on January 31, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for two unilateral breast ultrasounds (76641) provided on January 20, 2020.
You asked the Plan to pay for two unilateral breast ultrasounds. You say that this is documented in the records. The Plan denied your request. The Plan says that the number of units is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 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 two unilateral breast ultrasounds Our reviewer says that the billing of two units of 76641 is supported by the records. Our physician reviewer found the submitted medical records clearly document that breast ultrasounds were performed bilaterally in 4 quadrants of each breast. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of two unilateral breast ultrasounds have been met. Therefore, we decided that the Plan has to pay for two unilateral breast ultrasounds (76641) provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this device will lessen the amount of finger pokes. The Plan denied your request. The Plan says criteria for a continuous glucose monitor 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 looked at the file and Medicare rules. The enrollee is not insulin treated therefore the Medicare coverage criteria for a CGM is not met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial denture (D5213) and lower partial denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you lost your apartment and is now homeless and lost your partial dentures and you would like them replaced. The Plan denied your request. The Plan says this request exceeds the benefit 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. This service is covered once every 5 years. The records show that these services were rendered on July 9, 2018. 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 upper partial denture (D5213) and lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevision services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that the requested provider is the best facility for eye treatment.The Plan denied your request. The Plan says the service requested may be provided 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 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 requestedprovider 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 OON services. Therefore, we decided that the Plan does not have to pre-approvevision services 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 for deep sedation/general anesthesia - first 15 minutes (D9222)
and bone replacement graft for ridge preservation - per site (D7953) provided on February 5, 2020.
You asked the Plan to pay for the dental services. You say that you were not told the two (2) procedures were
not covered. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Review of the file shows that bone replacement graft for ridge preservation - per site (D7953 is not listed in
your EOC as a covered benefit. Furthermore, medical needs do not expand the scope of benefited procedures.
Therefore, we decided that the Plan does not have to pay for deep sedation/general anesthesia - first 15 minutes
(D9222) and bone replacement graft for ridge preservation - per site (D7953) provided on February 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a physical therapy facility on January 29, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you did not know that prior authorization was required. The Plan denied your request. The Plan says they have partially overturned their decision. The Plan says that 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 $30 copayment for outpatient rehabilitation services/in-network/physical therapy. You have been asked to pay a $30 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation services/in-network/physical therapy 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 physical therapy provided by a physical therapy facility on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - two surfaces, anterior (D2331 x 2)
and resin-based composite - three surfaces, anterior (D2332) provided on February 14, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the
plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for resin-based
composite - two surfaces, anterior (D2331 x 2) and resin-based composite - three surfaces, anterior (D2332)
provided on February 14, 2020.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the ground mileage and ambulance service provided on January 13, 2020.
You asked the Plan to pay for the ground mileage and ambulance service. You say that the enrollee's hospice was terminated on January 8, 2020. The Plan denied your request. The Plan says that Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the enrollee's applicable hospice election information. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Thus, the plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the ground mileage and ambulance service provided on January 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional Polysomnography (95810).You asked the Plan to pre-approvethe additional Polysomnography. You say that you would like reconsideration because the member has excessive daytime sleepiness and has been waking up gasping for breath.The Plan denied your request. The Plan says this service is inclusive in the approved test (95844).The Plan mustfollow Medicare rules. Medicare rules say that services that are not medically necessary are not covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional Polysomnography have not been met. The record indicates that this member has been approved for Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist (95811). The services of the requested test (95810) are inclusive in the test that has been approved.Therefore, we decided that the Plan does not have to pre-approveadditional Polysomnography (95810)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal provided on February 5, 2020.
You asked the Plan to pay for the root canal. You say that it was too far to drive to the endodontics specialist and needed someone closer. The Plan denied your request. The Plan says out-of-network dental services are 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 3, 2019.