Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness equipment.
You asked the Plan to pay for fitness equipment. You say that you were unaware the benefit only went until December 31, 2020.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. The benefit the member is requesting was a special allowance that was active in response to the COVID-19 epidemic, and only ran from October 1 -December 31, 2020. The member purchased the exercise equipment January 8, 2021, therefore it is not covered.Therefore, we decided that the Plan does not have to pay for the fitness equipment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel.You asked the Plan to pre-approve targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis panels are only covered for certain indications.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of targeted genomic sequence analysis panel have not been met.Therefore, we decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you are being told that the insurance did not receive the referral from your primary doctor. You say this is the first year you are having a problem with the bill being paid. 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 provided on August 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341).You asked the Plan to pre-approve the periodontal scaling and root planing (D4341). You say that you have a high risk of gingivitis.The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral -complete series of radiographic images (D0210) received January 26, 2021.You asked the Plan to pay for the intraoral -complete series of radiographic images. You say that you were told that all services you received would be covered.The Plan denied your request. The Plan says the contract clearly states that services not limited to periodic oral evaluation (D0210), comprehensive oral evaluation (D0150) and prophylaxis (cleaning) (D1110).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 intraoral -complete series of radiographic images (D0210) received January 26, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivered meals, including preparation, per meal
(S5170).

You asked the Plan to pre-approve home delivered meals. You say that you have a caregiver that helps you
bath and do small tasks around the house. You cannot cook for yourself and is wheelchair bound. The Plan
denied your request. The Plan says the enrollee does not meet the criteria as the records do not indicate that the
enrollee has been recently admitted to the hospital.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

The Plan offers a meal benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply
in this case. The Plan offers a meal benefit when released from an inpatient hospital stay or skilled nursing
facility. The documentation provided does not show that the enrollee had been recently admitted to the
hospital. Though the plan offers a meal benefit in excess of Medicare coverage, the enrollee does not meet the
criteria. Therefore, we decided that the Plan does not have to pre-approve home delivered meals, including preparation, per meal (S5170).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the alfiberceptinjection (J0178), the administration of the injection (67028), and the telehealth visit (Q3014) provided from January 25, 2021, to February 16, 2021.You asked the Plan to pay for the physician services. You say that regarding the claim for February 16, 2021, you were no longer on hospice. You say that you were seeing physician assistants on telehealth systems. You also say that these have always been covered. You say that The Plan denied your request. The Plan says the claims would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.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. Although the enrollee ended Medicare Hospice benefits on February 10, 2021. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay for the alfibercept injection (J0178), the administration of the injection (67028), and the telehealth visit (Q3014) provided from January 25, 2021, to February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 genetic testing (81433, 81432).You asked the Plan to pre-approve BRCA 1 and BRCA 2 genetic testing. You say that you need this because your family members have been diagnosed with cancer.The Plan denied your request. The Plan says this is not covered for enrollees without a personal history of cancer.The Plan must follow Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 genetic testing is not reasonable and necessary, thus is non-covered, for individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. Such testing is considered screening and is excluded by Medicare statute. We looked at the file and Medicare rules. The record does not show that you have a personal history of cancer. Based on this information, we decided that Medicare rules for coverage of BRCA 1 and BRCA 2 genetic testing have not been met.Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 genetic testing (81433, 81432).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that this will increase you day to day performance.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) for tooth # 8, and
surgical extractions (D7250) for teeth # 5 and 12.

You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says bone replacement graft is not listed as a covered service. The Plan says that
surgical extractions are not listed as covered services either.

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 bone replacement graft (D7953) for tooth # 8, and surgical extractions (D7250) for teeth # 5 and 12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biological materials to aid in soft osseous tissue regeneration (D4265 x 4), second stage implant surgery (D6011 x 4), semi-precision attachment abutment (D6052 x 4), and bone graft at the time of implant placement (D6104 x 4).
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says the requested services are not listed as covered 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, 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 biological materials to aid in soft osseous tissue regeneration (D4265 x 4), second stage implant surgery (D6011 x 4), semi-precision attachment abutment (D6052 x 4), and bone graft at the time of implant placement (D6104 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381).You asked the Plan to pre-approve the dental services (D4341, D4381). You say that the requested services are necessary.The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the periodontal scaling and root planing(D4341) and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing -one to three teeth per quadrant (D4342) provided January 7, 2021.You asked the Plan to pay for the periodontal scaling and root planing. You say that there have been inconsistencies in how claims have processed from this provider's office for recent claims.The Plan denied your request. The Plan says the claim was processed as in-network however you had not yet met your deductible at the time of service therefore you are responsible for the cost.
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 periodontal scaling and root planing when the services are medically necessary and reasonable. We looked at the file and Medicare rules. At the time of the service, you had not yet met your dental deductible. Since the cost of the service was less than the remaining deductible amount, you are responsible for the cost of the service. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing -one to three teeth per quadrant (D4342) provided January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT code 99308) provided
to the enrollee on January 6, 2021, by an out-of-network provider.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the
provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the
enrollee's visit before providing services to the enrollee as outlined on their identification card.

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 subsequent nursing facility care (CPT code 99308) provided to the enrollee on January 6, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the parathyroidectomy or exploration of parathyroid(s) (60500) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the parathyroid services. You say that you wish to see this provider because she specializes in parathyroid issues and does a minimally invasive procedure to correct. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The 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 the parathyroidectomy or exploration of parathyroid(s) (60500) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and the unspecified preventive procedure, by report (D1999) received December 16, 2020.

You asked the Plan to pay for the dental services (D1999, D0150). You say that the exam was for a problem with your tongue. The Plan denied your request. The Plan says the frequency for the comprehensive oral evaluation has been exhausted.

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 either in excess of what is covered or not among those covered under this benefit. The Plan has submitted evidence that you last received a comprehensive oral evaluation on February 18, 2020. This procedure is only covered once every three years by the Plan. The benefit was exhausted when you received the comprehensive oral evaluation on December 16, 2020. The Plan does not offer coverage for procedure code D1999. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and the unspecified preventive procedure, by report (D1999) received December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7140) and removal of residual tooth
roots (D7250) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the extraction procedures. You say that these services are necessary. The
Plan denied your request. The Plan says out-of-network dental care is not covered by the Plan. The provider in
question does not participate with the Plan's dental 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers. 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 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
an extraction (D7140) and removal of residual tooth roots (D7250) to be provided by an out-of-network
provider.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the enrollee does not have documented skilled nursing or therapy needs. Her care needs at this point are custodial and can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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 were admitted for non-operative management of a C2 fracture and thigh hematoma after a motor vehicle collision. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 you do not qualify for SNF coverage. You do have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living (ADLs) in the setting of your prior stroke. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve SNF care.