Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
You asked the Plan to pre-approve Myocardial perfusion imaging, tomographic (SPECT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that SPECT nuclear cardiac studies are covered to differentiate ischemic heart disease from dilated cardiomyopathy. 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 Myocardial perfusion imaging, tomographic (SPECT). Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has some risk factors for CAD but a stress test in 2017 was negative. However, per the physicians notes, the enrollee now reports chest discomfort along with shortness of breath. The reason stated for the need for a nuclear SPECT stress is due to abnormal EKG at baseline. The CMS criteria state that SPECT nuclear cardiac study may be used to diagnose ischemic heart disease (which is at issue here) and it therefore meets NCD 220.12 SPECT criteria. Given the reported symptoms of chest pain and shortness of breath and that three years have elapsed since the enrollee's last stress test, it appears medically necessary as well to diagnose possible ischemic CAD. Therefore, the enrollee meets criteria for the requested 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 Myocardial perfusion imaging, tomographic (SPECT) have been met. Therefore, we decided that the Plan has to pre-approve Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe flu vaccine provided on October 2, 2019.You asked the Plan to reimburse you forthe services provided. You say that you sent the payment to the facility.The Plan denied your request. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  We looked at the file and the rules. Yourplan does cover flu shots once each flu season. However, the service at issue was not billed correctly. The documentation does indicate that the Plan provided the reimbursement form needed to resolve the issue. Reimbursement cannot come from Part B as it was not applied there. Therefore, we decided that the Plan does not have to reimburse you forthe flu vaccine provided on October 2, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea sleep study. You say that the in-network providers are in a Covid-19 hot spot.The Plan denied your request. The Plan says there are in-network provider 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 sleep study to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after November 25, 2020.

You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 above 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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are near baseline of functioning. Your improvement plateaued and skilled rehab services were discontinued. You are medically stable. There are no complex daily wound care needs, parental medication needs, or required care for a feeding tube. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you no longer require the necessary services on an inpatient basis, at a SNF level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the facet joint nerves.
You asked the Plan to pre-approve the facet RFA procedure. You say that you have had back pain for many
years, and your doctor feels this procedure would be helpful. The Plan denied your request. The Plan says this
procedure cannot be approved since you have only had a single MBB previously.
The Plan must follow Medicare rules. Medicare rules say that RFA of the facet joint nerves can be covered
when dual MBBs provide at least 50% pain relief.
The documentation shows that you have only undergone a single MBB. A second confirmatory MBB is
necessary in order to justify coverage of the RFA procedure. Therefore, we decided that the Plan does not have
to pre-approve a radiofrequency ablation (RFA) of the facet joint nerves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forimplant supported porcelain/ceramic crown (D6065) and surgical placement of mini implant (D6013) provided on January 28, 2020.You asked the Plan to pay forimplant supported porcelain/ceramic crown and surgical placement of mini implant. You say that the service should be covered.The Plan denied your request. The Plan says the service provided 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 forimplant supported porcelain/ceramic crown (D6065) and surgical placement of mini implant (D6013) provided on January 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network outpatient mental health care provided on May 16, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 contract states outpatient mental health care requires both referral and prior authorization. The 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. 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 forout of network outpatient mental health care provided on May 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the therapies needed can be provided at a lower level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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-approveskilled nursing facility (SNF) services for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1 gm capsule
You asked the Plan to pre-approve Vascepa. You say that this drug is medically necessary for your condition. The Plan denied your request. The Plan says the drug falls under Part D coverage but member has no Part D pharmacy benefit. The Medicare Advantage plan does not cover outpatient prescription drugs.
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 Vascepa 1 gm capsule.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on November 21,
2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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. 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 outpatient mental health
services provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 1, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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. 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 out of network physician
services provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe resin-based composite of two surfaces (D2392) and resin-based composite of three surfaces (D2393) provided on February 24, 2020 by an OON provider.You asked the Plan to pay more forthe resin-based composites. You say that you would like the Plan to consider covering more for these services.The Plan denied your request. The Plan says the OON member responsibility was applied correctly.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 rulesapply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay more forthe resin-based composite of two surfaces (D2392) and resin-based composite of three surfaces (D2393) provided on February 24, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on April 17, 2020, through April 23, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9502 has a status indicator of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9502 has a status indicator of I. This means that CPT code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) provided on April 17, 2020, through April 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 18, 2020 to March 11, 2020.
You asked the Plan to pay for home health services. You say that this should be processed as in-network. The Plan denied your request. The Plan says this was billed with an incorrect type of bill.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the final claim was billed with an invalid type of bill code, 0324. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 18, 2020 to March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.You asked the Plan to pre-approvea power seat elevation feature. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicarerules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 14,2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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. 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 out of network physician services provided to the enrollee on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.
You asked the Plan to pay for incontinence supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the request does not meet Medicare guidelines for coverage.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics (L3000).You asked the Plan to pre-approvefoot orthotics. You say that foot orthotics are necessary as you have difficulty walking due topain in your feet.The Plan denied your request. The Plan says foot orthotics are not a covered benefit under your contractual policy for your condition.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-approvefoot orthotics (L3000)
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approverepairs for a power wheelchair.You asked the Plan to pre-approverepairs for a power wheelchair. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says as the cost of the repairs has exceeded the cost of replacement and the power wheelchair is close to 5 years old, repairs cannot be approved at this time. Replacement is required.The Plan must follow Medicare rules. Medicare rules say that repairs can only be covered up to the estimated cost of replacement.In this case, the Plan has covered $20,137.20 in repairs for this power wheelchair. This is more than the estimated cost to replace this power wheelchair. As such, no further repairsare covered, though replacement is an option if requested.Therefore, we decided that the Plan does not have to pre-approverepairs for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2331) for tooth # 25 provided.

You asked the Plan to pay for the filling for tooth # 25. You say that called the plan for information as you had not received an information booklet yet. You say that you were advised by a plan representative that you were eligible for 2 check-ups and teeth cleaning per year at 100% and that you had $2,000 per year in additional dental coverage. You say that there was no mention of the 50% coverage or limit of teeth per visit. You also say that you would like your plan to cover the 50% of the dental bill that you received as a result of your most recent dental appointment.The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan says that the frequency limit has been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 2 fillings per calendar year has been exhausted. The record shows that the Plan paid 50% for the fillings for teeth # 24 and 26.Therefore, we decided that the Plan does not have to pay for the filling (D2331) for tooth # 25 provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. You say that the enrollee requires this medication to maintain
quality of life. The Plan denied your request. The Plan says Eliquis to be administered at home is not Medicare
covered under 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 pre-approve Eliquis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 3, 2020.
You asked the Plan to pay for the physician's services. You say that the primary care physician told you that
you did not need a referral. The Plan denied your request. The Plan says the Plan has to pay for care from outof-
network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The
Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they
approved in advance.
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 and the referring provider are not network providers with the Plan. The Plan
did not pre-approve the physician's services. 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 physician's services provided on
July 3, 2020.