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

We decided that the Plan does not have to pay for the resin-based composites (D2392 and D2393) provided on June 29, 2020 by an OON provider.

You asked the Plan to pay for the resin-based composites. You say that your provider said they applied for coverage with your plan but were not contacted back. You also say that you would like help covering this bill. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the resin-based composites (D2392 and D2393) provided on June 29, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 25, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 25, 2020 by an out-of-network (OON) provider.
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 does not meet criteria.

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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 12, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional epidural injections.
You asked the Plan to pre-approve additional epidural injections. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for additional injections have not been met.
The Plan follows Medicare rules. Medicare rules say that a documented response is required before additional epidural injections will be approved. 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 additional epidural injections. Our reviewer says that the requested procedure is not medically necessary and reasonable. Our physician reviewer found this 72-year-old woman has chronic low back pain. In this case, there is a lack of documentation of the success of the previous epidural steroid injection. Therefore, the request is deemed not 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 additional epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve additional epidural injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and the retinal imaging provided on April 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the eye exam and retinal imaging. You say that you were not informed by the Plan or the provider's office that your insurance was no longer accepted. The Plan denied your request. The Plan says no prior authorization was 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 eye exam and retinal imaging provided on April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections (27096).

You asked the Plan to pre-approve SI joint injections. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of an SI joint injection in the absence of a physical examination documentation positive provocation testing have not been demonstrated in the peer-reviewed literature.

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 SI joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed literature. In this case, there is no documentation on physical examination of tenderness to the SI joint and no mention of SI provocative testing being completed with positive findings. The review has determined that the requested sacroiliac joint injections are not 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 SI joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracentesis represented by code 32555 provided on September 1, 2020.
You asked the Plan to pay for code 32555. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. Medicare says there are two CPT modifiers that were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure. In this case, the medical record does support the service as being unrelated to the global procedure; however, code 32555 was not billed with the appropriate modifier indicating that the service was unrelated and rendered during the postoperative period of the global procedure.
Therefore, we decided that the Plan does not have to pay for the thoracentesis represented by code 32555 provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided on November 10, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for injection services provided on November 10, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided June 8, 2021.

You asked the Plan to pay for periodontal scaling and root planing. You say that periodontal scaling should be covered. The Plan denied your request. The Plan says that light scaling is a covered service however the periodontal scaling and root planing is not a covered service.

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 periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (K0554) and supplies
(K0553), provided on April 8, 2021.
You asked the Plan to pay for the continuous glucose monitor and supplies. You say that the items are
medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate
the provider discussed the medical necessity for the requested items.
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 relevant medical records which support medical necessity for the supplies provided
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation
without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor
(K0554) and supplies (K0553), provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on May 14, 2021.

You asked the Plan to pay for the crown. You say that you have been with this dentist for quite some time and the dentist was in-network. You say that you were not informed the dentist was not authorized by the Plan and you shouldn't be responsible. The Plan denied your request. The Plan says out-of-network dental services are 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367), preventive procedure (D1999), topical application of fluoride varnish (D1206), periodontal maintenance (D4910), and periodontal procedure (D4999) provided on April 21, 2021 by a provider who has opted out of Medicare.
You asked the Plan to pay for the dental services. You say that you would like to appeal these services. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective November 29, 2017, to November 29, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.
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 by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367), preventive procedure (D1999), topical application of fluoride varnish (D1206), periodontal maintenance (D4910), and periodontal procedure (D4999) provided on April 21, 2021 by a provider who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the one surgical placement of implant body: endosteal implant (D6010) and surgical extraction (D7210) or pay more for the additional endosteal implant (D6010) provided on March 23, 2021.

You asked the Plan to pay for the one endosteal implant and surgical extraction and to pay more for the additional endosteal implant. You say that by no means should this work be denied. The Plan denied your request. The Plan says the annual limit allowed by your dental plan has been paid for this benefit year.

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 Plan offers a maximum allowance of $1,500 every year for non-Medicare covered preventive and comprehensive dental services. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the March 23, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the one surgical placement of implant body: endosteal implant (D6010) and surgical extraction (D7210) or pay more for the additional endosteal implant (D6010) provided on March 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on September 1, 2020, to October 9, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for outpatient mental health services. You say that you would like this paid. You say that you need a therapist. The Plan denied your request. The Plan says there are in-network providers 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on September 1, 2020, to October 9, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutment (D6056) and the implant supported crown (D6066) provided on January 25, 2021.
You asked the Plan to pay for the dental services. You say that the services you received for tooth # 30 was medically necessary. The Plan denied your request. The Plan says the prefabricated abutment is not listed as a covered service. The Plan says that the implant supported crown 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated abutment (D6056) and the implant supported crown (D6066) provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need this for safety. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 14, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 14, 2021, forward. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric care from September 14, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 14, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 14, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from September 14, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 14, 2021, forward.
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met. It is not reasonable to expect that the enrollee would be able to fully benefit from or participate in the intensity of services provided at an IRF. The necessary services can be safely provided in a lower level of care.

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 that 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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.