Persius/hicric huggingface dataset:
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 documentation provided supports that LTACH care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 pre-approve an endodontic therapy (D3320) and four gingival irrigations (D4921 x4).

You asked the Plan to pre-approve the endodontic therapy and gingival irrigations. The Plan denied your request. The Plan says these services are 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, 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 an endodontic therapy (D3320) and four gingival irrigations (D4921 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve renewal for rental of a home ventilator.

You asked the Plan to pre-approve renewal for rental of a home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 renewal for rental of a home ventilator. Our reviewer says that the documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has severe COPD with chronic hypoxemic respiratory failure, but there is no documentation of CO2 retention. There is no evidence that BiPAP has been tried and failed. Therefore, the enrollee does not meet criteria for the requested home ventilator. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of renewal for rental of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve renewal for rental of a home ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network.

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 lab work provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve the therapy. You say that you have severe pain in both arms, and numbness and cramping in both hands for the past three months. The Plan denied your request. The Plan says this will not be received as an adjunct to another therapeutic treatment.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee nerve block.

You asked the Plan to pre-approve Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (64450). You say that you need the injection because your x-rays show your knees are bone to bone. The Plan denied your request. The Plan says there is not enough evidence that shows this procedure is as safe and effective as standard treatments.

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 Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (64450). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure. Therefore, the request is deemed not medically reasonable or 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 Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch (64450) have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee nerve block.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on July 9, 2019.

You asked the Plan to pay for the psychotherapy services. You say that this claim was filed untimely because you did not receive proper notice of the enrollee's benefit determination. You also say that the services provided were medically necessary. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date when the services were rendered. The Plan also says that this claim was filed past the allowed 12-month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychotherapy services was not filed until September 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.

You asked the Plan to pre-approve bone marrow aspiration. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage 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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, in this reviewer's opinion, the request for bone marrow aspirate is not medically reasonable or necessary for the approved lumbar fusion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.

You asked the Plan to pre-approve a raised toilet seat. You say that you have bruising from holding the door handle to stand back up. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. 

While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 29, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on January 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement provided on August 27, 2020, and November 5, 2020.

You asked the Plan to waive the copayments for debridement. You say that you disagree with the way the claims were processed and you feel that you should only owe a $50 specialist copayment for the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $600 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received debridement at an outpatient hospital facility on August 27, 2020. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $192.29, which is less than the $600 copayment. You received debridement at an outpatient hospital facility on November 5, 2020. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $192.29, which is less than the $600 copayment. 

The total amount you owe is: $384.58. 

You have been asked to pay the total copayment amount of $384.58 for debridement. Debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for debridement provided on August 27, 2020, and November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete maxillary denture and complete mandibular denture provided on August 13, 2020 by an OON provider.

You asked the Plan to pay more for the complete maxillary denture and complete mandibular denture. You say that the Plan should pay more for the dentures. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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, you are responsible for a 75% coinsurance, as well as for the difference between the billed amount and allowed about for services provided OON. Therefore, we decided that the Plan does not have to pay more for the complete maxillary denture and complete mandibular denture provided on August 13, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 29, 2020.

You asked the Plan to pay for the nurse practitioner 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 nurse practitioner services provided on October 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health skilled nursing services provided on September 28, 2020, to September 29, 2020.

You asked the Plan to pay for the home health services. You say that these services are medically necessary and should be covered. The Plan denied your request. The Plan says these home health services are not payable when billed on a professional claim.

The Plan must follow Medicare rules. Medicare rules say that home health services must be billed on an electronic or paper institutional claim. 

The code G0299 represents home health services which must be billed on an institutional claim. Therefore, we decided that the Plan does not have to pay for the home health skilled nursing services provided on September 28, 2020, to September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that this will help you. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 13, 2020.

You asked the Plan to pay for the dental services. You say that the last time that you received these services was on January 27, 2020. You also say that these services were provided past the 6 month frequency limitation. The Plan denied your request. The Plan says 1 oral exam and 1 prophylaxis are covered per calendar year. The Plan also says that the frequency limits for these services have 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 limits for these services have been exceeded. The record shows that the Plan paid for a periodic oral evaluation and prophylaxis that you received on January 27, 2020. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.

You asked the Plan to pre-approve the complete maxillary denture. You say that you are on a limited income and cannot afford to pay for the denture. 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, 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 maxillary denture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole-body bone and joint imaging scan.

You asked the Plan to pre-approve a whole-body bone and joint imaging scan. You say that the records provided support the need for the requested imaging. The Plan denied your request. The Plan says the requested imaging is not indicated at this time.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a whole-body bone and joint imaging scan. Our reviewer says that the requested whole-body bone and joint imaging scan is not considered medically reasonable and necessary in this case. Our physician reviewer found the notes provided were devoid of a reason or explanation for why a bone scan would be needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a whole-body bone and joint imaging scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a whole-body bone and joint imaging scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two periodontal scalings and root planings (D4341 x2) and a maxillofacial prosthesis (D5999).

You asked the Plan to pre-approve the scalings and planings and maxillofacial prosthesis. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are 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, 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 two periodontal scalings and root planings (D4341 x2) and a maxillofacial prosthesis (D5999).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve the diagnostic medial branch blocks
.
You asked the Plan to pre-approve the diagnostic medial branch blocks. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that there is no clinical information documenting medical necessity.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the diagnostic medial branch blocks. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member has tried PT, Home exercises, Tylenol, Ultram,Flexeril and Oxycodone. She had Epidural steroid injections without pain relief. 

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 diagnostic medial branch blocks have been met. Therefore, we decided that the Plan has to pre-approve the diagnostic medial branch blocks.