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

We decided that the Plan does not have to pay for the resin-based composite crown (D2390).

You asked the Plan to pay for the dental service. You say that you do not have dental coverage. You also say that you have major issues with your teeth and need to have work done. The Plan denied your request. The Plan says the teeth do not have good prognosis. The Plan says that for this service to be approved there must not be decay or infection that goes into the nerve.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental service when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the dental service. Our reviewer says that the resin-based composite crown is not medically necessary. Our physician reviewer found the documentation provided with this case was inadequate. The reviewer found there was no narrative describing the condition of these teeth, the bone support, the need for root canal therapy or the prognosis of the treatment. The reviewer also found that radiographs submitted were not diagnostic. Therefore, the reviewer found that the resin-based composite crown 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 the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pay for the resin-based composite crown (D2390).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone density scan (77080).

You asked the Plan to pay for a bone density scan. You say that you did not want to wait to get this testing due
to COVID-19. The Plan denied your request. The Plan says this is only covered every two years.

The Plan must follow Medicare rules. Medicare rules say that Medicare pays for a screening bone mass
measurement (BMM) once every two years (at least 23 months have passed since the month the last covered
BMM was performed).

We looked at the file and Medicare rules. The record shows that you last received a covered bone mass
measurement. Less than 23 months passed between that service and the service at issue.
Based on this information, we decided that Medicare rules for coverage of a bone density scan have not been
met. Therefore, we decided that the Plan does not have to pay for a bone density scan (77080).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.

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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says that daily skilled therapy is not required to restore function.

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 the requested admission is medically reasonable and necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and has had a decline in physical functioning. Her baseline functional status is independent, and she requires navigating stairs in order to get into her home. Further rehab services would be appropriate to improve function, as a practical matter, the daily skilled services can be provided at a skilled nursing facility. She is medically stable without an acute exacerbations of chronic back pain with weakness. Her physical function is not at her baseline and she can receive services at a SNF. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no claim for the ordering physician.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records show that the enrollee has a degenerative lumbar condition. There is no instability documented. Lumbar bracing is not needed for degenerative back pain without instability.

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 pay for an orthosis (L0650) provided to the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the imaging services.

You asked the Plan to waive the copayment for the imaging services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received imaging services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a breast ultrasound on the right and also one on the left. You have been asked to pay a $111.93 copayment for each ultrasound, totaling $223.86. The imaging services fall within the Outpatient diagnostic tests 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 the imaging services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery (43248).

You asked the Plan to waive the copayment for the outpatient surgery. You say that the copayment should only be $105. The Plan denied your request. The Plan says the correct copayment was 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 $175 copayment for ambulatory surgical center services.

You have been asked to pay a $175 copayment for the outpatient surgery. The outpatient surgery falls within the ambulatory surgical center services 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 outpatient surgery (43248).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient surgery (93458).

You asked the Plan to waive the deductible for the outpatient surgery. You say that you were told there would only be a $350 copayment. The Plan denied your request. The Plan says the correct cost-sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible and $325 copayment for outpatient surgical services.

The service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible and $325 copayment for outpatient surgical services. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery was received. Therefore, we decided that the Plan does not have to waive the deductible for outpatient surgery (93458).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pentazocine-Naloxone Tablet.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the requested drug is intended for enrollee 'self-administration'.

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 Pentazocine-Naloxone Tablet.

Benefits for the medication 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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 currently the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT Code E0466).

You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan denied your request. The Plan says the Medicare rules have not been 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 the home ventilator.

Our physician reviewer found the coverage criteria for a home ventilator are not met. You were recently hospitalized with acute respiratory failure secondary to heart failure with reduced ejection fraction, pulmonary hypertension, and pleural effusions. A diagnosis of obstructive sleep apnea (OSA) is mentioned, but it is not clear if this has been documented with polysomnography. There is no documentation of CO2 retention. There is no diagnosis of chronic obstructive pulmonary disease (COPD), generalized neuromuscular disease, or thoracic restrictive disease. You tolerated BiPAP in the hospital, and there is no documentation of BiPAP failure. A home ventilator is not medically necessary, and the denial is upheld.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT Code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services and cases in which the Plan authorizes use of out-of-network providers.

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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Panitumumab (J9303).

You asked the Plan to pre-approve Panitumumab. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 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 Panitumumab. Our reviewer says that the medication is medically necessary. Our physician reviewer found this enrollee has a right sided colon cancer at least stage III and possibly stage IV that is KRAS wild-type. The service is reasonable and 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 Panitumumab have been met. Therefore, we decided that the Plan has to pre-approve Panitumumab (J9303).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (CPT Code 22869).

You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of your health problem.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (CPT Code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the comprehensive periodontal exam (D0180) and prophylaxis (D1110).

You asked the Plan to pay the in network rate for the dental services. You say that you were advised by a plan representative that the provider in this case was in network. The Plan denied your request. The Plan says the provider in this case is not in network at the location that you received these services. The Plan says that the appointment that you made with the provider's office was a location where the recommended providers are not in network.

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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the comprehensive periodontal exam (D0180) and prophylaxis (D1110).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99217).

You asked the Plan to pay for physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services (99217).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0157, G0299).

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed with the correct details.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes G0157, & G0299 are not supported in the medical record. Specifically, the claim did not include a valid location (Q) code for the home health services. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0157, G0299).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lidocaine Pad.

You asked the Plan to pre-approve lidocaine pad.. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not covered under Part B Medicare prescription drugs.

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 lidocaine Pad.