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

We decided that the Plan does not have to pay for an implant (D6010), bone graft (D6104), and guided tissue
regeneration (D4266) provided on December 22, 2020.
You asked the Plan to pay for an implant, bone graft, and guided tissue regeneration. You say that you want the
Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered
benefits.
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 pay for an
implant (D6010), bone graft (D6104), and guided tissue regeneration (D4266) provided on December 22, 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 the enrollee meets the Medicare criteria for appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.
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 receiving appropriate care at the present acute care facility. There are no services available at the LTACH that the enrollee requires which are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and topical application of fluoride varnish (D1206) provided December 8, 2020.
You asked the Plan to pay for the dental cleaning and fluoride treatment. You say that you should have 3 cleaning covered per year because of your documented history of gum disease. The Plan denied your request. The Plan says the services as billed, have a limit of 2 procedures per year.
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 cleaning and fluoride treatment when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The Plan provided documentation showing that these services, D1110 and D1206 have already been covered by the Plan twice in the same Plan year. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning and fluoride treatment have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and topical application of fluoride varnish (D1206) provided December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate specific antigen (PSA) screening testing provided on December 11, 2020.
You asked the Plan to pay for PSA screening testing. You say that your doctor performed a PSA test in June 2020 and due to the results and your family history your doctor instructed you to take this additional test. The Plan denied your request. The Plan says the denial of payment for this test is correct, because PSA screening testing is covered once every 12 months and you had a previous PSA screening test on June 9, 2020.
The Plan must follow Medicare rules. Medicare rules say that PSA screening testing is covered once every 12 months for men who have attained the age of 50. We looked at the file and Medicare rules. You previously had a PSA screening test on June 9, 2020; therefore, this test exceeds the covered frequency of once every 12 months. Based on this information, we decided that Medicare rules for coverage of PSA screening testing have not been met. Therefore, we decided that the Plan does not have to pay for prostate specific antigen (PSA) screening testing provided on December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 10, 2020, to October 15, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary so the Plan should pay this claim. The Plan denied your request. The Plan says that there is no documentation that a complicated or extended course of care was reasonably anticipated after the revision.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 10, 2020, to October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (33533, 33257, 33518, 33508) provided November 9, 2020.
You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says the surgical assistant services are not eligible for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (33533, 33257, 33518, 33508) provided November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) received January 20, 2021 from a non-participating provider.
You asked the Plan to pay for the limited oral evaluation. You say that the requested service should be paid for by the Plan. The Plan denied your request. The Plan says the Plan does not cover dental services when provided by a non-participating dental 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) received January 20, 2021 from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the urinalysis provided on December 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and the urinalysis. You say that you were referred to the specialist by urgent care. You say you could not be seen by your PCP until the next day. The Plan denied your request. The Plan says no prior authorization was 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 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 office visit and the urinalysis provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pancreatic cancer. Keytruda is not FDA-approved for the treatment of recurrent metastatic pancreatic cancer. Its use is also not supported by the National Comprehensive Cancer Network (NCCN) guidelines or major drug compendia. The Keytruda is 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 Keytruda.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on September 24, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the provider was not responsible for getting authorization because the enrollee was in a nursing facility. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior 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 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 domiciliary or rest home visit provided on September 24, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 1, 2020, through January 21, 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 the services provided are not payable as they were rendered by a provider that does not participate in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, these services were rendered by a provider that does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from January 1, 2020, through January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on January 14, 2021.
You asked the Plan to pay for the comprehensive evaluation. You say that you thought this was just a regular evaluation and did not realize the dentist was billing for this service. You do not understand how you had reached your maximum, because this was your first dental appointment of the year. The Plan denied your request. The Plan says a comprehensive oral evaluation may be covered once every 36 months. You had a comprehensive oral exam in June of 2019, which is less than 36 months before the date in question.
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 evaluation is requested in a frequency not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on January 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from July 29, 2019, through March 18, 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 the services provided are not payable as they were rendered by a provider that does not participate in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, these services were rendered by a provider that does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from July 29, 2019, through March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for free soft tissue graft procedure (D4277 x 2) provided on October 14, 2020.
You asked the Plan to pay for the dental services. You say that the services were deemed necessary by your dentist. You say that if you did not have this service, your teeth would fall out due to deterioration of your gums. The Plan denied your request. The Plan says free soft tissue graft procedure 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 pay for free soft tissue graft procedure (D4277 x 2) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 3, 2020, by an
OON provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
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 physician services provided on November 3,
2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 testing provided on September 25, 2020.
You asked the Plan to pay for the Guardant 360 testing. 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 as billed.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the Guardant 360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant 360 testing provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 genetic testing provided on October 7, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zyclara.
You asked the Plan to pre-approve Zyclara. You say that the request is medically necessary. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.
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 Zyclara.
Benefits for Zyclara may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frames (V2020) purchased on July 29, 2020 from an out-of-network provider.
You asked the Plan to pay for the frames. You say that your glasses broke and needed to be replaced out-of-state. The Plan denied your request. The Plan says routine vision services received out-of-network are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided in-network. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the frames have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass frames (V2020) purchased on July 29, 2020 from an out-of-network provider.