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

We decided that the Plan does not have to pre-approve surgical placement of an implant (D6010), a bone replacement graft (D7953), a custom fabricated abutment (D6057), an abutment supported crown (D6058), and inhalation of nitrous oxide (D9230).

You asked the Plan to pre-approve surgical placement of an implant, a bone replacement graft, a custom fabricated abutment, an abutment supported crown, and inhalation of nitrous oxide. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 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 pre-approve surgical placement of an implant (D6010), a bone replacement graft (D7953), a custom fabricated abutment (D6057), an abutment supported crown (D6058), and inhalation of nitrous oxide (D9230).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 5, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram and blood collection provided March 16, 2021.
You asked the Plan to pay for the electrocardiogram and blood collection. You say that you believe these services should be covered as part of the enrollee's yearly checkup. The Plan denied your request. The Plan says services required by a third party are excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. In this case, the requested services were completed specifically for the enrollee to be allowed admission into a nursing home. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram and blood collection have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram and blood collection provided March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crown repairs necessitated by restorative material failure (D2980 x2).
You asked the Plan to pre-approve the crown repairs. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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. Therefore, we decided that the Plan does not have to pre-approve two crown repairs necessitated by restorative material failure (D2980 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity brace (L1833, L2397) provided October 3, 2020.
You asked the Plan to pay for the extremity brace. You say that the brace was medically necessary. The Plan denied your request. The Plan says the item was provided as the result of an unsolicited telephone consult and is not covered.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the extremity brace have not been met. Therefore, we decided that the Plan does not have to pay for an extremity brace (L1833, L2397) provided October 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two second stage implant surgeries (D6011 x2).

You asked the Plan to pre-approve the second stage implant surgeries. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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. Therefore, we decided that the Plan does not have to pre-approve two second stage implant surgeries (D6011 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), and to pay more for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on March 31, 2021 by an OON provider.

You asked the Plan to pay for the intraoral periapical x-rays, bitewing x-rays, or pay more for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that your dental work should have been totally covered by the Plan as it always was in the past. The Plan denied your request. The Plan says the intraoral periapical x-rays are considered to be part of another diagnostic service. The Plan says that the bitewing x-rays are considered to be part of a service reported on another line of this claim. The Plan also says that you are responsible for the coinsurance plus the difference between the providers charge and the amount allowed by your coverage for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis.

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 are responsible for an 80% coinsurance for exams and cleanings, and an 80% coinsurance for dental x-rays. The Plan appropriately applied the 80% coinsurance for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110). The first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274) are all a part of the complete series of intraoral x-rays (D0210), which was approved and paid appropriately by the Plan. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewing x-rays (D0274), and to pay more for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on March 31, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the unlisted musculoskeletal system
provided on November 9, 2020.
You asked the Plan to pay for the office visit and the unlisted musculoskeletal system. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are
not medically necessary.
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 office visit and the unlisted
musculoskeletal system. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found you were diagnosed with erectile
dysfunction. You underwent focused linear compression therapy for this condition. This treatment currently
does not have sufficient high quality evidence to support its general use for your condition and would be
considered investigational. Therefore, you did not meet criteria for the services received.
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 office visit and the unlisted musculoskeletal system have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit and the unlisted musculoskeletal
system provided on November 9, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Reblozyl.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found that you have a diagnosis of low-risk myelodysplastic syndrome and failure of Aranesp. The records support that Rebolyzyl is reasonable and medically necessary and safe and effective for your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Reblozyl.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4) to be rendered by an OON provider.

You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says services are only covered by the enrollee's Health Plan for in network dentists. The Plan also says that you are not in the Plan's provider network.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4) to be rendered by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
re-cement or re-bond crown (D2920) provided April 13, 2021.
You asked the Plan to pay for the limited oral exam and re-bonding of crown. You say that it is illogical that
these services are not covered. The Plan denied your request. The Plan says these services are not covered
under your dental 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
limited oral evaluation - problem focused (D0140) and re-cement or re-bond crown (D2920) provided April 13,
2021.
Your complaint about which services are covered under the Plan's dental benefits is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 25, 2021.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental services provided by an out-of-network provider are not covered under the Plan's supplemental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services provided by an out-of-network provider are not covered. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automated blood pressure cuff.

You asked the Plan to pre-approve automated blood pressure cuff. You say that your doctor wants you to have this due to your gaining some weight and needs to monitor your blood pressure. The Plan denied your request. The Plan says these services are not covered under Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve automated blood pressure cuff.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway
pressure (CPAP) device.

You asked the Plan to pre-approve these services. You say that you need the battery because of electrical
problems in your home. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressure
(CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis rendered on March 10, 2021.

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 provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 

We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the date of service at issue. 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 orthosis rendered on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 in the Medicare rules section. 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for scaling and root planning (D4346) provided February 1, 2021.
You asked the Plan to pay for scaling and root planning. You say that the service was medically necessary. The
Plan denied your request. The Plan says that this service is not covered when patient has had prior treatment for
periodontitis.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. No medical records were provided to the IRE for review. No copy of the criteria
that states that "This service is not covered when patient has had prior treatment for periodontitis" was provided
to the IRE for review. Per the Evidence of Coverage provided, the service is a covered benefit. Therefore, we
decided that the Plan has to pay for scaling and root planning (D4346) provided February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on February 18, 2021.

You asked the Plan to waive the coinsurance for radiation therapy services. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. The Plan denied your request. The Plan says the coinsurance applied correctly.

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 20% coinsurance per visit for radiation therapy.

You have been asked to pay $63.65, which is 20% of the allowed amount for radiation therapy services. The allowed amount is $318.23 (20% x $318.23 = $63.65). Radiation therapy services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 coinsurance for radiation therapy services provided on February 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided March 9, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are non-covered.
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 self-administered drugs (A9270) provided March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on March 19, 2021.

You asked the Plan to waive the copayment for these services. You say that you did not have a telehealth appointment on this date. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each covered visit or consultation in an outpatient location with a specialist.

Review of the file shows that you received specialist services on March 19, 2021. The medical records confirmed that you received services for a neoplasm of the skin. You have been asked to pay a $15 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist 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 the specialist services rendered on March 19, 2021.