Persius/hicric huggingface dataset:
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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly
moderate assist for functional transfers and maximum assist for activities of daily living (ADL's) and a less
intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation shows that the request is for use of Keytruda to treat the enrollee with metastatic clear cell kidney cancer that was previously treated with Sutent. The use of Keytruda as monotherapy is not FDA approved in this setting. The requested use is not supported by any of the CMS approved compendia. The enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December
10, 2019.
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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not
supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. 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 drug testing
services provided to the enrollee on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant maintenance procedure (D6080) provided on
February 11, 2020.
You asked the Plan to pay for the dental service. You say that you see a dentist twice per year to have your
implants cleaned. You also say that this service should be covered as a dental cleaning. The Plan denied your
request. The Plan says the implant maintenance 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 the
implant maintenance procedure (D6080) provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the core build up and crown for tooth # 8. We decided that the Plan does not have to pre-approve the core build up and crown for tooth # 6, and pontics for teeth # 7 and 10.
You asked the Plan to pre-approve the core build up and crown for teeth #6 and 8, and pontics for teeth # 7 and 10. You say that you have sensitive gums. You say that you will have issues with the adhesive that holds dentures. You say that parts of your partial dentures are hanging and you have to use super glue to hold them in place.
You also say that you have gained 20 pounds since January due to eating processed food as it is soft and you have to gum it. The Plan says that the requested dental services are not medically necessary.
We decided that the Plan has to pre-approve the core build up and crown for tooth # 8.
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 dental services 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 pre-approve the dental services. Our reviewer says that the crown and core build up for tooth # 8 is medically necessary. The reviewer found that the provided documentation shows a large restoration involving more than 50% of the coronal structure. Therefore, the reviewer found that the core build up and crown for tooth # 8 are medically necessary.
Therefore, we decided that the Plan has to pre-approve the core build up and crown for tooth # 8.
We also decided that the Plan does not have to pre-approve the core build up and crown for tooth # 6, and pontics for teeth # 7 and 10.
The reviewer also found that the crown and core build up for tooth # 6, and the pontics for teeth # 7 and 10 are not medically necessary. The reviewer found the criteria for coverage for a crown and core buildup (D2950) for tooth #6 have not been met since significant coronal breakdown is not evident. The reviewer found that the replacement of missing teeth # 7 and 10 with fixed bridge pontics is not medically necessary since a upper partial denture has been approved to replace the missing upper posterior teeth, therefore teeth #7 and 10 could easily be replaced with the partial denture.
Therefore, we decided that the Plan does not have to pre-approve the core build up and crown for tooth # 6, and pontics for teeth # 7 and 10.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the surgical extractions for teeth # 21 and 22. We decided that the Plan does not have to pre-approve the surgical extractions for teeth # 23, 24, 25, 26, 27.
You asked the Plan to pre-approve the surgical extractions for teeth # 21 and 22. You say that you need the extractions. The Plan says that the extractions are not medically necessary.
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 surgical extractions when the services are medically necessary and reasonable.
We decided that the Plan has to pre-approve the surgical extractions for teeth # 21 and 22.
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 extraction of teeth # 21, 22, 23, 24, 25, 26, 27. Our reviewer says that the surgical extraction of teeth # 21 and 22 is medically necessary. Our physician reviewer found that the provided x-rays reveal significantly decayed teeth # 21 and 22 such that attempted forceps removal would most likely result in fracture of the clinical crown that would subsequently require surgical removal.
Based on this information, we decided that the Plan's rules for coverage of the extraction of teeth # 21 and 22 have been met. Therefore, we decided that the Plan has to pre-approve the surgical extractions for teeth # 21 and 22.
We also decided that the Plan does not have to pre-approve the surgical extractions for teeth # 23, 24, 25, 26, 27.
The reviewer says that the surgical extraction of teeth # 23, 24, 25, 26, and 27 is not medically necessary. The reviewer found that teeth #23-27 have intact clinical crowns and would not be expected to require removal of bone in order to remove these teeth. The reviewer found that the provided documentation does not show there is clear anticipation that bone would be needed to be removed and therefore a lesser code would be more appropriate and should be used. The reviewer found that based on the documentation provided, there is no apparent need for surgical extractions for #23,24,25,26 or 27.
Based on this information, we decided that the Plan's rules for coverage of the extraction of teeth # 21, 22, 23, 24, 25, 26, 27 have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical extractions for teeth # 23, 24, 25, 26, 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and palliative (emergency) treatment of dental pain - minor procedure (D9110) provided on February 13, 2020.
You asked the Plan to pay for the dental services. You say that the description in the summary of benefits does not differentiate between types of x-rays; it just says x-rays of teeth. 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 intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and palliative (emergency) treatment of dental pain - minor procedure (D9110) provided on February 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from September 9, 2019 to November 7, 2019.
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 the provider is billing for inpatient coding for an outpatient claim.
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 denied codes are not supported in the medical record. Specifically, the claim is being billed as inpatient when it is an outpatient claim. 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 home health services provided to the enrollee from September 9, 2019 to November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan eye drops.
You asked the Plan to pre-approve the Rocklatan eye drops. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the drug being requested is not covered by the enrollee's Medicare Part B contract.
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 Rocklatan eye drops.
Benefits for the Rocklatan eye drops 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 dental services provided on June 12, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were given names of dentists in-network by the Plan and you found one that didn't exist and the other does not accept your insurance. You state you took it upon yourself to find a dentist as the pain you were experiencing was severe. The Plan denied your request. The Plan says you do not have out-of-network 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. The provider is not in-network and your EOC clearly states, the plan has partnered with another Dental PPO to provide your dental benefit. To locate a network provider, search the online provider directory. Therefore, we decided that the Plan does not have to pay for the dental services provided on June 12, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided while the member was residing at. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained for these services.
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 has network providers available who can provide 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 skilled nursing services provided on November 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you are aware you can only use your benefit once every five years. You also say that your dentures fell out due to your remaining bottom teeth falling out. The Plan denied your request. The Plan says this service is only covered 1 time in a 60-month period. The Plan also says that the records show that you have already had 1 of these services done in that time period.
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, mandibular partial dentures are limited to one (1) per 60 months. The record shows that you received a mandibular partial denture (D5214) on October 2, 2017 and your mandibular partial dentures benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care from August 30,
2019 through September 1, 2019.
You asked the Plan to waive the deductible for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received inpatient hospital care from August 30, 2019 through September 1,
2019. The allowed amount for the inpatient hospital services was $1,049.74. You had not met any of your
$1,364.00 Part A deductible as of this claim. The plan applied $1,049.74 as the deductible to the claim for dates
of service August 30, 2019 to September 1, 2019.
You have now met your Medicare Part A deductible amount of $1,364.00 as follows: The Hospital (dates of service August 30, 2019 to September 1, 2019) in the amount of $1,049.74, The Provider (date of service August 31, 2019) in the amount of $205.42 and the Provider (date of service
September 1, 2019) in the amount of $108.84 ($1,049.74 + $205.42 + $108.84 = $1,364.00). The deductible in
the amount of $1,049.74 was correctly applied to the claim from the Hospital for dates of
service August 30, 2019 to September 1, 2019. 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 deductible for inpatient
hospital care from August 30, 2019 through September 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for AZO Bladder Control Weight Loss Supplements purchased
July 14, 2019.
You asked the Plan to pay for the AZO supplements. You say that the benefit guide is not clear and you use
AZO for bladder control. The Plan denied your request. The Plan says alternative medicines are not covered
under the over the counter benefit
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and AZO is an
OTC item. Therefore, we decided that the Plan does not have to pay for AZO Bladder Control Weight Loss
Supplements purchased July 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out of network provider, 
You asked the Plan to pre-approve a referral to an out of network provider. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to seek services with a non-preferred provider. The plan states there are equally qualified in network providers available to you that can provide the care and treatment you are requesting.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out of network provider,
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 8, 2020 to January 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital care provided was not medically necessary.
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 enrollee presented to Hospital Emergency Department on 1/8/20 with complaints of not having had a bowel movement for three days. She reported trying Magnesium Citrate and MiraLax with no success. The enrollee stated that she would typically not have problems with constipation. Reported low abdominal pain that was achy, non-radiating, waxes/wanes, was worse with pressure and not alleviated by anything she could identify. She tolerated food well, denied nausea/vomiting, fevers. Recently had a urinary tract infection (UTI), treated with Ciprofloxacin. Enrollee was following up at the hospital for HIV, reported undetectable viral load, CD4 count reportedly 1000-1500. The review has determined that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 January 8, 2020 to January 10, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for gastrointestinal pathogen testing (0097U) provided on October 11, 2019.
You asked the Plan to hold you harmless for gastrointestinal pathogen testing. You say that you needed this test because you were sick. The Plan denied your request. The Plan says that this test was not medically necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Health Plan follows these rules. You received gastrointestinal pathogen testing from the  Hospital. The Hospital is a contract provider. The file does not show that the Health Plan provided notice that gastrointestinal pathogen testing would not be covered. Under Medicare rules, this means gastrointestinal pathogen testing is considered approved by the Health Plan. Therefore, we decided that the Plan has to hold you harmless for gastrointestinal pathogen testing (0097U) provided on October 11, 2019.