Persius/hicric huggingface dataset:
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 you need SNF care. 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 you are a 75-year-old female with respiratory failure, end-stage renal disease on dialysis and diabetes. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for your condition. The Plan denied your request. The Plan says the requested Vertiflex procedure is experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex procedure is experimental. More research is needed to show safety and efficacy of the Vertiflex device. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 

1. A neurological condition;
2. Myopathy; or 
3. Congenital skeletal deformity. 

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition,
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from September 1, 2021, to October 11, 2021.

You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not aware of copayments for physical therapy. You say the physical therapy has been helping but you cannot afford it. The Plan denied your request. The Plan says you have been asked to pay 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 a $20 copayment for each Medicare-covered outpatient rehabilitation service, treatment, or evaluation.

You have been asked to pay a $20 copayment for each of the physical therapy visits. ($20 x 3 visits = $60). The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy visits provided from September 1, 2021, to October 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.

You asked the Plan to pre-approve Hymovis. The Plan denied your request. The Plan says the enrollee has not failed, has an intolerance or contraindication to analgesics.

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 Hymovis. Our physician reviewer found that in this case, the record indicates that the enrollee has osteoarthritis of the knee. The record does not indicate that the enrollee has failed, or has a contraindication to conservative treatment as defined by the coverage criteria. The elements of the coverage criteria are not satisfied. Therefore, the requested Hymovis is not considered medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve the fixed partial denture sectioning. 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 a fixed partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of tooth roots (D7250) and inhalation of nitrous oxide (D9230).
You asked the Plan to pre-approve the dental services. You say that you have been to different dentists. You also say that you were advised that your tooth cannot be salvaged. The Plan denied your request. The Plan says removal of residual tooth roots is not listed as a covered service. The Plan says that inhalation of nitrous oxide is not listed as a covered service either.
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 removal of residual tooth roots and inhalation of nitrous oxide are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pre-approve removal of tooth roots (D7250) and inhalation of nitrous oxide (D9230).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested imaging service have not been met.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. 

We reviewed the file and the Medicare rules. We find that the enrollee is 78 years old. This age is not within the required range of 55-77 years old for the requested LDCT scan. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of arformoterol tartrate.

You asked the Plan to pre-approve arformoterol tartrate. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of formoterol (Perforomist) before it will approve arfomoterol.

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. 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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records, nor any documented attempts to obtain medical records. Without records, we cannot determine whether the enrollee has tried and failed - or has a contraindication to the use of - the Plan's preferred drug of Perforomist. The Plan has not provided any rationale for this denial of authorization except for the Plan's step therapy requirements. Therefore, the Plan has not shown that their decision to deny authorization is correct or justified according to Medicare rules and the enrollee's contract with the Plan. Therefore, we decided that the Plan has to pre-approve use of arformoterol tartrate.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography (93306) provided on June 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the echocardiography. You say that at the time of service an authorization was not obtained. You also say that you believe the patient was admitted for medical necessity. The Plan denied your request. The Plan says both the referring and attending providers are non-participating with the Plan. The Plan also says that prior authorization was not obtained.
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 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 the echocardiography (93306) provided on June 2, 2021 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided July 19, 2021.

You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the records only support 1 unit of the code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that 2 units of CPT code 71045 are not supported in the medical record. The medical record only supports 1 unit of CPT code 71045. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 17, 2021.
You asked the Plan to pay for the dental services. You say that you were put on a medication for 5 years that could lead to bone loss. You say that your dentist wants to make sure this does not occur. You also say that you do not want to lose your teeth. The Plan denied your request. The Plan says 2 oral exams and prophylaxis are covered per plan year. The Plan says that 1 set of bitewing x-rays is covered per plan years. The Plan also says that the frequency limits have 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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for an oral exam, prophylaxis, and bitewing x-rays that you received on February 10, 2021. The record also shows that the Plan paid for an oral exam and prophylaxis that you received on May 12, 2021. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 17, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a BEMER System therapy device for the enrollee.
You asked the Plan to pre-approve this device. You say that this device can help improve circulation. The Plan denied your request. The Plan says this device is not covered by Medicare.
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 can be purchased commercially and is classified as a self-help device. This item is available to the 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 BEMER System therapy device for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0012M) provided January 21, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for code 0012M. 

We looked at the file and Medicare rules. The billed code is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0012M) provided January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2920) and limited oral evaluation (D0140), provided on April 8, 2021, and May 17, 2021.

You asked the Plan to pay for the crown and limited oral evaluation. You say that the services should be covered. The Plan denied your request. The Plan says Non-network dentists have not agreed to provide services at contracted fees. If you see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged fees when visiting an out-of-network dentist.

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 crown (D2920) and limited oral evaluation (D0140), provided on April 8, 2021, and May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) or pay more for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on August 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the complete series of intraoral x-rays and to pay more for the periodic oral evaluation and periodontal maintenance. You say that these dental charges are so far above what you consider customary. You also say that the Plan's data is obsolete and is not fair to the patient. The Plan denied your request. The Plan says the complete series of intraoral x-rays is not a covered expense under your dental plan. The Plan also says that the periodic oral evaluation and periodontal maintenance were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for these services.
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, complete series of intraoral x-rays (D0210) not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for a periodic oral evaluation (D0120) and periodontal maintenance (D4910), plus the difference between the billed amount and allowed amount for the services being received OON. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) or pay more for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on August 23, 2021 by an out-of-network (OON) provider.
Your complaint about your disappointment with the Plan's coverage 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 two core buildups, including any pins when required (D2950) provided on July 20, 2021.
You asked the Plan to pay for the core buildups. You say that you would like these services to be covered. The Plan denied your request. The Plan says this service is not a covered expense under your dental 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 pay for the two core buildups, including any pins when required (D2950) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided February 11, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1846).

You asked the Plan to pre-approve the knee orthosis. You say that the knee brace is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered for recent injury or surgery, or in cases where there is documented knee instability. 

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 knee orthosis. Our reviewer says that the requested knee brace is not medically necessary. Our physician reviewer found the documentation does not reveal any knee instability or recent injury.

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1846).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a skin substitute application (15271) provided June 7, 2021.

You asked the Plan to pay for the skin substitute application. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 15271 is not supported in the medical record. Specifically, the skin substitute application procedure was billed without a required skin substitute product code. Based on this information, we decided that Medicare rules for coverage of the skin substitute application have not been met. Therefore, we decided that the Plan does not have to pay for a skin substitute application (15271) provided June 7, 2021.