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

We decided that the Plan does not have to pay for the laboratory services rendered on August 24, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), drugs or medicaments dispensed in the office for home use (D9630), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), therapeutic parenteral drug, single administration (D9610), and unspecified preventive procedure, by report (D1999) provided September 30, 2020.

You asked the Plan to pay for the extraction, deep sedation, drugs for home use, nitrous oxide, parenteral drug and unspecified preventative procedure. You say that you were referred by your dentist for emergency services. The Plan denied your request. The Plan says the services have been reprocessed by the Plan despite being provided by a Medicare opt-out provider since the condition was emergent in nature. However, the services are excluded from the Plan's dental 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. 

In this case the Plan has reprocessed the tooth extraction and provided documentation that they have covered 5-% of the cost. Therefore, we decided the Plan does not have to provide additional reimbursement for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 30, 2020.

Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining 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 deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), drugs or medicaments dispensed in the office for home use (D9630), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), therapeutic parenteral drug, single administration (D9610), and unspecified preventive procedure, by report (D1999) provided September 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 patient appears to be at baseline.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that Zilretta is preferred. The Plan denied your request. The Plan says the enrollee has not tried and failed Dexamethasone and Triamcinolone.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Zilretta. Our physician reviewer found that the enrollee has a past medical history of rheumatoid arthritis and osteoarthritis of multiple joints including the knees. The Plan requires a trial of Dexamethasone and Triamcinolone before they will approve the requested drug. The enrollee has not tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less effective, or likely have adverse effects for 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional outpatient physical therapy services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says other options should be considered at this time including a home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional therapy is not generally accepted as specific and effective therapy for your condition, beyond what was already approved by the plan. You should be able to transition to an independent home exercise program at this point. The requested services are not part of a maintenance program. 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 additional outpatient physical therapy services.
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 you cannot walk without shoe inserts. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1851) and a suspension sleeve (L2397) provided on October 31, 2020.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 for the supplies provided in this case. Specifically, the document submitted as proof of delivery cannot be verified to correspond to the items at issue. 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 a knee brace (L1851) and a suspension sleeve (L2397) provided on October 31, 2020.
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 there is no documentation provided necessitating admission to a LTACH. At the time of the request, the enrollee's status is unstable, with fever. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this scan will not obviate the need for EGD and colonoscopy.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found in this case, the enrollee has had a 30 pound weight loss. The hemoglobin is decreased by 10%. The enrollee has a history of hepatitis C. No ultrasound or endoscopy has been performed. The prostate specific antigen is normal and the enrollee has not seen the oncologist. A CT scan is not medically reasonable or necessary at this time based upon the documentation provided. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a
segmental pneumatic appliance (E0669).
You asked the Plan to pre-approve a pneumatic compression device and a segmental pneumatic appliance. You
say that you are in pain due to a diagnosis of lymphedema. The Plan denied your request. The Plan says the
requested item is not reasonable and necessary.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk, and/or abdomen.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that your lymphedema extends
onto the chest, trunk, and/or abdomen. The item coded E0669 is not separately payable when the base item is
not covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652) and a segmental pneumatic appliance (E0669).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve professionally applied fluoride varnish (D1206) and bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve fluoride varnish and bone replacement graft. You say that you are suffering, and the dental services are necessary. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve professionally applied fluoride varnish (D1206) and bone replacement graft for ridge preservation (D7953).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 13, 2020.
You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.
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
physical therapy. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physical therapy provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on November 23, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this
service should be covered. The Plan denied your request. The Plan says this service is 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
problem focused limited oral evaluation (D0140) provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140).
You asked the Plan to pay for the limited oral evaluation - problem focused.. You say that you had a broken
tooth and needed the service. The Plan denied your request. The Plan says the requested service is in excess of
your annual allowable frequency.
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 service is in excess of
that covered under this benefit. The Plan allows one limited oral evaluation - problem focused, per year. The
Plan has submitted evidence that you received a limited oral evaluation on February 24, 2020. Therefore, we
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received
December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on July 29, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, but the documentation indicates the specimen was obtained in an office setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code, but the record indicates that the member's face-to-face services was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483 and 80307) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the extraction of teeth #2, 18, and 29.

You asked the Plan to pre-approve the extractions. The Plan denied your request. The Plan says that the extractions are not medically necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the extractions when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the extractions. Our reviewer says that the requested dental extractions are medically reasonable and necessary in this case. Our physician reviewer found that due to the lack of coronal tooth structure of teeth #2, 18 and 29, a cutting procedure for removal of the retained root structures (D7250) meets the criteria for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extractions have been met. Therefore, we decided that the Plan has to pre-approve the extraction of teeth #2, 18, and 29.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance transport provided on
October 24, 2020.
You asked the Plan to waive the cost share for the ambulance transport. You say that you were billed for more
when you already paid. The Plan denied your request. The Plan says the cost share applied correctly.
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 your in-network deductible is $300. This is the amount you have to pay out-ofpocket
before we will pay our share for your covered in-network medical services. Until you have paid the innetwork
deductible amount, you must pay the full cost of your covered in-network services. Your contract with
the Plan also says that after your yearly deductible is met, you pay $100 for each one-way Medicare-covered
ambulance transport.
The item or service you asked the Plan to waive the cost share for falls within the "Ambulance services" benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that your in-network $300
deductible applies to ambulance services. This cost sharing is a contractual obligation that had not been met at
the time the ambulance transport was received on October 24, 2020. Therefore, $300 has been applied to meet
your in-network deductible.
Since your $300 deductible has been met, you have also been asked to pay $56.07, which is less than the
standard $100 copayment for the ambulance transport. 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 cost share for the
ambulance transport provided on October 24, 2020.
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 your requesting orthotics to alleviate the pain from flat feet and planter fasciitis. 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.