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

We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110), complete
mandibular dentures (D5120), and a comprehensive exam (D0150).
You asked the Plan to pre-approve complete maxillary dentures (D5110), complete mandibular dentures
(D5120), and a comprehensive exam (D0150). You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says you have exhausted these dental benefits for the 2020 benefit 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.
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 at this time. The Plan contract clearly limits you to dentures once every
five years and comprehensive exams once every three years. The file shows you received dentures and a
comprehensive exam in 2019. Therefore, we decided that the Plan does not have to pre-approve complete
maxillary dentures (D5110), complete mandibular dentures (D5120), and a comprehensive exam (D0150).
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 enrollee still needs assistance. The Plan denied your request. The Plan says the requested IRF care 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 29, 2020 with severe hyponatremia. He was treated with antibiotics for a foot ulcer. He is now medically stable. He requires set up for basic activities of daily living. He has no complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need for acute rehab nursing care. He may benefit from further therapy but does not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on February 7, 2020.You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan says that there is a copay for ambulance services.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 $195 copay for per one way trip for Medicare-covered ground ambulance services. You have been asked to pay a $195 copay for the ambulance transport. The ambulance transport falls within the one way trip for Medicare-covered ground ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copay for the ambulance transport provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve false tooth for bridge, tooth 30 (D6242) white glass with gold cap for bridge teeth 29, 31 (D6752). You asked the Plan to pre-approve the dental services. You say that please review for allowance for a bridge.The Plan denied your request. The Plan says the dental services are not medically necessaryMedicare generally doesnot 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 services when the services are medically necessary and reasonable.  In this case, we find that the requested dental service is not supported by the records provided. The records provided were insufficient. There were no dental records provided from the provider. There were no dental x-rays provided from the provider. The records show that the plan had attempted to obtain the needed documents. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvefalse tooth for bridge, tooth 30 (D6242) white glass with gold cap for bridge teeth 29, 31 (D6752).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on May 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicarerules. There is no valid physician order in the submitted documentation. 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 pay forthe drugtesting rendered on May 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories (E2203, K0108, E2201).
You asked the Plan to pre-approve the wheelchair accessories. You say that the features are medically
necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that wheelchair options are covered when 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 wheelchair accessories. Our
reviewer says that the requested accessories are not medically necessary. Our physician reviewer found while
the 22" manual wheelchair is medically necessary, the requested accessories are not. The record does not
support that the enrollee would be able to utilize the functions. The power assist feature is not medically
necessary as the enrollee requires assistance with all functional transfers and activities of daily living.
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 wheelchair accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve wheelchair accessories (E2203, K0108, E2201).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you have had three strokes and have difficulty with your sugar levels dropping too low. You say that you have an alert system so that you can call for help if you fall. You stated that you are still feeling very weak and it takes at least two people to help you up. You say that you pay for insurance coverage and you feel like the ambulance charges should be covered. You stated that if you fall you can't lay on the floor for days while waiting for help and if you are not injured then there is no reason to go to the hospital which would cost even more. 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 March 6, 2020 and March 9, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient admission for total knee arthroplasty.You asked the Plan to pre-approveinpatient admission for total knee arthroplasty. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 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 inpatient admission for total knee arthroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do have a high body mass index (BMI), whichcould make mobilization more difficult, but that in and of itself does not meet the threshold for an acute inpatient stay versus skilled nursing facility (SNF) care post-procedure, as you would not remain in the acute setting for all your post-surgery rehabilitation services. The review has determined that the inpatient admission for a total knee arthroplasty is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for total knee arthroplasty have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient admission for total knee arthroplasty.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 28, 2019.You asked the Plan to pay for the ambulance transport todialysis. You say that the transport was medically necessary.The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport todialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance transport to dialysis have not been met.Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was 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 the drug testing services provided on August 14, 2019.
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 services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs are met in the current inpatient hospital setting.
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 not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided by a participating provider on March 2, 2020.You asked the Plan to waive the copayment for a colonoscopy. You say that your doctor wants you to get a colonoscopy every year since you had cancer 2 years ago. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for colorectal cancer screening and outpatient surgery. You have been asked to pay a $400 copayment for a colonoscopy. a colonoscopy falls within the colorectal cancer screening and outpatient surgery 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 waivethe copayment for a colonoscopy provided by a participating provider on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature and power standing feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300) and power standing feature (E2301). You say that the power seat elevation feature would reduce cervical strain and pain, and make transfers and reach easier. The Plan denied your request. The Plan says Medicare rules say that a seat lift and power standing feature do not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. These features are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature and power standing feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolotherapy(M0076) and a platelet rich plasma injection (0232T) provided on November 22, 2019.You asked the Plan to pay for prolotherapy and a platelet rich plasma injection. You say that you were told these services would be covered.The Plan denied your request. The Plan says these services are not covered under Medicare rules.The Plan must follow Medicare rules. Medicare rules say that prolotherapyis non-covered by Medicare and platelet rich plasma injections are considered not reasonable and necessary.We looked at the file and Medicare rules.The services at issue are not covered under Medicare rules.Based on this information, we decided that Medicare rules for coverage of prolotherapy and a platelet rich plasma injection have not been met.Therefore, we decided that the Plan does not have to pay for prolotherapy (M0076) and a platelet rich plasma injection (0232T) provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe power operated vehicle. You say that your current powerwheelchair is over 7 years old and is unable to be repaired.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. The plan has confirmed that in-network vendors are available.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-approvea power operated vehicle to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 21, 2019.You asked the Plan to pay for the ambulance transport from dialysis. You say that the transport was medically necessary.The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ambulance transport from dialysis.Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance transport from dialysis have not been met.Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer of cast metal for resin bonded fixed prosthesis (D6545).
You asked the Plan to pre-approve the retainer. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.
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 retainer of cast metal for resin bonded fixed prosthesis (D6545).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on December 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 pay for the Guardant360 panel rendered on December 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee has used the 100 day SNF benefit for this benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 13, 2020
through April 18, 2020 and May 5, 2020 through July 6, 2020. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.