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 you need rehab to help you walk. You say that you cannot get out of bed and have fallen twice. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires or can tolerate an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 patient appears to be improving and more stable, requiring less than an additional 
25 days of acute care services, which can be completed in the current setting safely and effectively. The patient 
does not require services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current setting. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to 
a lower level of care may be considered soon when appropriate. 
 
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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy for liver cancer. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no current research that shows the requested type of treatment would improve 
your outcome. It has not been shown that your cancer type has responded well to the requested type of 
treatment. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack evidence that that Selective Internal Radiation Therapy (SIRT) improves survival 
or quality life in patients with metastatic colon cancer. It is not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiation therapy for liver cancer.
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 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 the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and confusion. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
does document a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda 100MG/4ML Solution (CPT Code J9271).You asked the Plan to pre-approvethe medication. You say that the drug is necessary.The Plandenied your request. The Plan says the drug is not 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 the medication. Our physician reviewer found The requested use of Keytruda is FDA-approved for the enrollee's diagnosis but only as a single agent. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. There is no data to support combination proposed (carboplatin and docetaxel).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 medication have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda 100MG/4ML Solution (CPT Code J9271).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 May 4, 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 by you on May 
4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone assessment and management service provided on May 8, 2020. You asked the Plan to pay for the practitioner service. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim 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. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 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. Therefore, we decided that the Plan does not have to pay for the telephone assessment and management service provided on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on June 4, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that you are retired and on a limited income. 
You say that you can only pay $100 per month. The Plan denied your request. The Plan says the bone 
replacement graft is not listed as a covered service. The Plan also says that any services not specifically listed 
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 pay for the bone 
replacement graft for ridge preservation (D7953) provided on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from August 7, 2019, to 
August 9, 2019. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says 
services not related to the enrollee's medical care are not covered under the enrollee's plan. 
 
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 pay for the self-administered drugs 
provided from August 7, 2019, to August 9, 2019.  
 
Benefits for the self-administered drugs 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 limited oral evaluation (D0140) provided on June 10, 2020.

You asked the Plan to pay for the dental service. You say that your regular dentist sent you to see the provider in this appeal for your broken tooth. You say that you did not know it would be considered an emergency exam at either dental office. The Plan denied your request. The Plan says emergency exams are covered one time in a 12 month period. The Plan says the frequency limit has 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 limit has been exceeded. The record shows the Plan paid for this service on May 20, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on January 6, 2020.

You asked the Plan to pay for the dental services. You say that the Evidence of Coverage and Plan's promotional material seem to indicate that the services should be covered. The Plan denied your request. The Plan says payments cannot be issued for services performed by an opt out provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

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 at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and periodontal maintenance 
(D4910) provided on January 29, 2020. 
 
You asked the Plan to pay for the panoramic x-ray (D0330) and periodontal maintenance (D4910). You say 
that the dentist office never called to verify dental benefits. You say that you weren't informed the procedures 
weren't covered. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330) and periodontal maintenance (D4910) provided on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting from December 2, 2019, to December 5, 2019.
You asked the Plan to reimburse you for the self-administered drugs. You say that you were in the hospital for 3 nights. You say that you were given your regularly prescribed medications. You say that since you were admitted as outpatient, the medications were not covered. You also say that you should not have to pay for these medicines. The Plan denied your request. The Plan says the drugs in this case are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan says the requested drug is not covered under Medicare Part B.
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 reimburse you for the self-administered drugs provided in an outpatient setting from December 2, 2019, to December 5, 2019.
Benefits for the self-administered drugs 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 comprehensive oral evaluation (D0150), the 2 extractions 
(D7140), and the alveoloplasty in conjunction with an extraction (D7310) provided by the 
out of network dental provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was not 
participating provider with the plan. You also say that you were not aware the services would not be covered. 
The Plan denied your request. The Plan says the provider in this case does not participate with the dental plan. 
The Plan also says that dental services that you receive from an non-participating dentist 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 when you receive them from a non-participating dentist. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the 2 extractions 
(D7140), and the alveoloplasty in conjunction with an extraction (D7310) provided by the 
out of network dental provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 10, 2019, to December 24, 2019.

You asked the Plan to pay for the skilled nursing services. You say that the enrollee was not enrolled in hospice during the time period that these services were rendered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on December 6, 2019. 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 skilled nursing services provided from December 10, 2019, to December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) and the core build up (D2950) for tooth # 3 provided on June 22, 2020.

You asked the Plan to pay for the dental services. You say that your coverage allows for cavities, fillings, and normal maintenance. You say that your dentist discovered you had a cavity in a tooth with a cap. You say that the cap had to be removed so the cavity could be fixed. You also say that you should not have to pay for a new one because of this. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service either. The Plan also says any services that are not listed 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. The Evidence of Coverage clearly states that any services that are not listed are not covered. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) and the core build up (D2950) for tooth # 3 provided on June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 23, 2020. 
 
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 procedure codes 37228 and 37232 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37228 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. The definition of 
code 37232 is revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each 
additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure). 
 
We find that CPT codes 37228 and 37232 are not supported in the medical record. Specifically, the operative 
report did not contain documentation of an open or percutaneous endovascular revascularization of a unilateral 
tibial or peroneal artery to support code 37228. Given that primary procedure code 37228 is not supported, add-
on code 37232 is also not supported. 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 surgical 
services rendered on March 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-rays. 
 
You asked the Plan to pay for the additional intraoral x-rays. You say that you told the dentist to check with 
insurance to see if everything they needed to do to your teeth was covered. You say that you don't feel 
responsible to pay this amount. The Plan denied your request. The Plan says your benefit 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, you also have a maximum benefit of 
one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-
rays provided.