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

 We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2) provided on June 28, 2021.  You asked the Plan to pay for the scalings and planings. You say that you do not know what a root planing is, but all you received that day was simply a routine cleaning, which is supposed to be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit 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 periodontal scalings and root planings (D4342 x2) provided on June 28, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to reduce the cost sharing for the cardiac ablation procedure you had at an outpatient hospital facility on May 18, 2021.  You asked the Plan to reduce the cost sharing for the cardiac ablation procedure. You say that your contract says that you only pay $250 for outpatient surgery, but you are being billed over $4,000. The Plan denied your request. The Plan says that you were charged 20% coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $250 copayment for outpatient surgery in an outpatient hospital facility.   The Plan says you must pay 20% coinsurance for the cardiac ablation procedure. It appears as though the Plan incorrectly categorized the services you received as diagnostic testing and therapeutic services.  This is not appropriate.  Outpatient hospitals bill using revenue codes.  These revenue codes are made up of specific procedure codes.  In this case, the Plan based the coinsurance it charged on the revenue code of 480 that was billed.  However, according to the full bill from the facility, the specific procedure codes that made up this revenue care are 93613, 93656, and 93662.  According to the Medicare Physician Fee Schedule, these codes are surgical codes, not diagnostic testing or therapeutic service codes.  As such, these services should be considered outpatient surgery. Based on the Plan contract, you cannot be asked to pay more than a $250 copayment for outpatient surgery in a hospital. Therefore, we decided that the Plan has to reduce the cost sharing for the cardiac ablation procedure you had at an outpatient hospital facility on May 18, 2021.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography (CT) services provided on October 19, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the CT services. You say that the services were medically necessary. 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) services provided on October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).  You asked the Plan to pre-approve Gel-One. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. The case file does not contain documentation that the enrollee has tried and failed the Plan's preferred alternatives. The documentation does not support that the Plan's preferred alternatives would likely be less effective, and/or would likely have adverse effects, for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a vacuum socket for prosthesis (L5781).  You asked the Plan to pre-approve a vacuum socket for prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says this specific vacuum socket is beyond the member's medical needs.  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 a vacuum socket for prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested vacuum socket for prosthesis (L5781) is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The physician documentation does not reveal extenuating factors on an exam or evidence supporting the need for the requested vacuum socket over a standard socket.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a vacuum socket for prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum socket for prosthesis (L5781).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for CoViD-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube.  The enrollee has been tolerating ventilator weaning. There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 29, 2021, and October 30, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on October 29, 2021, and October 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on October 29, 2021, and October 30, 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 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 you do appear to require physical therapy and occupational therapy services. There is inadequate information to say that you require (and could tolerate) an intensive inpatient rehabilitation therapy program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Unfavorable

 We decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), filling (D2381), and periodontal maintenance (D4910) provided from July 1, 2021, to August 11, 2021, by the out of network dentist.  You asked the Plan to reimburse you for the dental services. You say that your booklet says you pay 50% for periodic oral exam and are expecting a reimbursement of $49. You say that your booklet says periodontal maintenance is covered at 50% and are expecting a reimbursement of $75. You say that the booklet says you pay 55% for resin composite filling and are expecting a reimbursement of $119.25 The Plan denied your request. The Plan says that services received out of network are paid based on the allowed amount. The Plan says that out of network providers may also bill you for any amount greater than what the plan pays. The Plan also says that periodontal maintenance is not listed as 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 and periodic oral exam and filling are listed as covered, out of network cost share amounts apply to the allowed amount. Out of network dentists may also bill you for any amount greater than what the plan pays. Additionally, periodontal maintenance is not among those covered under the 2021 benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), filling (D2381), and periodontal maintenance (D4910) provided from July 1, 2021, to August 11, 2021, by the out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records do not show that you have had two medically reasonable and necessary diagnostic injections with each one providing at least 80% relief or that you have you received 50% relief for a period of six months from your previous destruction of paravertebral facet joint nerves.  

The Plan must follow Medicare rules. Medicare rules say that RFA can be covered if Medicare criteria is met.      

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 requested services are not considered medically reasonable and necessary in this case. The records do not show that you have had two medically reasonable and necessary diagnostic injections with each one providing at least 80% relief, or that you received 50% relief for a period of six months from the previous destruction of paravertebral facet joint nerves (RFA). Our physician reviewer found that your condition does not meet Medicare criteria for RFA.  

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 not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission for a total knee arthroplasty for the
enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan
denied your request. The Plan says the denial of the requested elective inpatient admission was appropriate
given the clinical scenario.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee is undergoing a planned total knee arthroplasty. The total knee
arthroplasty has been approved. The enrollee is medically stable and has been provided medical clearance to
undergo this elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The
review has determined that the record does not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient admission for a total knee arthroplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acupuncture to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the acupuncture. You say that this is a covered service and you do not need a prior authorization. The Plan denied your request. The Plan says the provider is out-of-network.  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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve acupuncture to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and complete series of intraoral x-rays (D0210) provided on October 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation and complete series of intraoral x-rays. You say that you received false information from Medicare because you were advised that this treating facility was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the call records do not indicate that you were told this provider was in-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 pay for the periodic oral evaluation (D0120) and complete series of intraoral x-rays (D0210) provided on October 6, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 28, 2021, to September 26, 2021.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says custodial services are not covered.  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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to provide medically necessary and reasonable treatment safely and effectively from 08/28/2021 through 09/12/2021. Daily skilled services were not required from 08/28/2021 through 09/12/2021. Services in the nursing facility appear custodial in this case (with part-time physical therapy and occupational therapy services provided) from 08/28/2021 through 09/12/2021.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 28, 2021, to September 26, 2021.