Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee suffered a traumatic fall which resulted in fractures. You say that, due to the severity of the enrollee's orthopedic deficits and sarcopenia, he had very slow improvement in function. You say that the enrollee is still impaired with his activities of daily living and his mobility. You say that the enrollee would benefit from a SNF rehabilitation course to continue to
make progress. The Plan denied your request. The Plan says the records indicate that the enrollee will continue to benefit from intensive rehabilitation in the current setting.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. The enrollee's needs can be safely and effectively met in the current IRF until he is prepared for a safe community or home discharge. There are no extenuating factors that require a SNF transfer. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain fused to high noble metal crown (D2750).
You asked the Plan to pre-approve the porcelain fused to high noble metal crown. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered service under the 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 porcelain fused to high noble metal crown (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided July 28, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the reasonableness of the provided equipment was not established.
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 pay for the shoulder elbow wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. 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 shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided July 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this request is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 beneficiary is a 74-year-old male with coronavirus. In this case, there are no identifiable skilled therapy service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services from October 29, 2020, to November 4, 2020.
You asked the Plan to waive the copayment for inpatient hospital services from October 29, 2020 to November 4, 2020. You say that you were readmitted to the hospital less than 24 hours after being discharged so you should not be responsible for both copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Medicare rules say that the second hospital stay is only part of the first hospital stay when you are admitting on the same calendar day you were discharged. The record shows you were re-admitted to the hospital on the following calendar day.
Your contract with the Plan clearly says that you must pay $450 per day for days 1 to 4 for Medicare-covered hospital care. You have been asked to pay $1,800 ($450 X 4 days = $1,800) for inpatient hospital services. Inpatient hospital services fall within the Inpatient Hospital Care 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 copayment for inpatient hospital services from October 29, 2020, to November 4, 2020.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 record shows the enrollee continues to receive acute care services and these have not been denied. The LTACH does not provide any services that are not currently available to the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular screening gene panel provided on March 2, 2021.
You asked the Plan to pay for the testing services. You say that the services were medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The records provided do not show that the results of the testing would be used to determine a specific treatment strategy. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular screening gene panel provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided September 18, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery. In this case, the proof of delivery includes an itemized receipt, but this document is missing information that corroborates the ordered item was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interim partial denture (Including retentive clasping materials and teeth) (CPT code D5820), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the enrollee is very motivated in keeping their remaining teeth. You state the enrollee's anterior tooth #8 is broken off at the gum line and the loss of the tooth has caused a big inconvenience to the enrollee. The Plan denied your request. The Plan says the service is 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve interim partial denture (Including retentive clasping materials and teeth) (CPT code D5820), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete lower denture provided on November 16, 2020.
You asked the Plan to pay more for the complete lower denture. You say that you haven't used any benefits prior to this service. You say that you are being billed $989 after paying $1,275 out-of-pocket The Plan denied your request. The Plan says the maximum amount for the year was paid with the processing of this claim.
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 $2,500 each year for comprehensive dental services. The Plan paid $2,500 toward your dental services received in 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the complete lower denture provided on November 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine 10 mg tablet.
You asked the Plan to pre-approve Cyclobenzaprine. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Cyclobenzaprine 10 mg tablet.
Benefits for Cyclobenzaprine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on September 30, 2020.
You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that the items at issue were used for the prevention of deep vein thrombosis or pulmonary embolisms. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for deep vein thrombosis or pulmonary embolisms.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on September 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services.
You asked the Plan to waive the copayment for skilled nursing facility services. You say that you experienced an injury resulting in the inability to walk. You say that you were sent to the skilled nursing facility and were
not informed by anyone that the services were not covered completely. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $160 per day for days 21 to 62 of skilled nursing facility services. You have been asked to pay $160 per day for skilled nursing facility services. The record shows that you were admitted to the SNF from November 25, 2019, through December 16, 2019, which counted as the first 21 days of your benefit period. Your admission from January 10, 2020, through January 31, 2020, was within the same benefit period. The January dates counted as days 22 to 42. Therefore, you are responsible for $160 copayment per day for days 22 to 42 ($160 x 21 days = $3,360). Please note, you are not charged for the day of discharge. Skilled nursing facility services fall within the Skilled Nursing Facility 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 copayment for skilled nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 1, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed to receive this exam from a new dentist in your new location in order to get your six-month checkup and cleaning. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, comprehensive oral evaluation (D0150) is limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on February 23, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you performed time-sensitive medically necessary tests which were reported to the ordering provider. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

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 drug testing provided on April 2, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require daily skilled nursing or therapy services in an inpatient setting. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound on November 19, 2020.
You asked the Plan to waive the deductible for an ultrasound on November 19, 2020. You say that you say you were unaware that the plan had a deductible. You say that you were not informed that you would need to pay for the ultrasound. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a deductible applied here, a $500 deductible for all items and services except those specifically excluded by the Plan contract.
You have been asked to pay $207.68 for an ultrasound. Ultrasounds fall within the benefit category Outpatient Diagnostics - Radiological Diagnostic Service, Not Including X-Rays. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible, which applies to Outpatient Diagnostics - Radiological Diagnostic Services, Not Including X-Rays. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on November 19, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal orthotic device (D7880) provided on April 2, 2021.
You asked the Plan to pay for an occlusal orthotic device. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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 pay for an occlusal orthotic device (D7880) provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.
You asked the Plan to pre-approve RFA. You say that this is medically necessary. The Plan denied your request. The Plan says no more than two sessions will be reimbursed in any rolling 12-month year.
The Plan must follow Medicare rules. Medicare rules say that no more than two radiofrequency sessions will be reimbursed per rolling 12 months. It is too soon to have this procedure again. RFA was previously received on November 5, 2020, and May 27, 2021. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.