Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need rehabilitation to safely live at home. The Plan denied your request. The Plan says that there are no noted skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal orthotic device (D7880).
You asked the Plan to pre-approve the occlusal orthotic device (D7880). You say that the member has temporomandibular joint and needs the mouth guard for pain. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the occlusal orthotic device (D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110), lower partial denture (D5214) and unspecified removable prosthodontic procedures (D5899) provided on May 13, 2021.
You asked the Plan to pay for the complete upper denture (D5110), lower partial denture (D5214) and unspecified removable prosthodontic procedures (D5899). You say that you were told you would be covered for dentures and partials. You say that you already paid $1,530 and you received a denial. The Plan denied your request. The Plan says the services 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 pay for the complete upper denture (D5110), lower partial denture (D5214) and unspecified removable prosthodontic procedures (D5899) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the modification of removable prosthesis (D5875), surgical implant placement (D6010), surgical access to an implant body (D6011) and custom fabricated abutment (D6057).
You asked the Plan to pre-approve the modification of removable prosthesis (D5875), surgical implant placement (D6010), surgical access to an implant body (D6011) and custom fabricated abutment (D6057). You say that the patient has a lower existing prosthesis that is not functioning adequately. You say that the implants and abutments are required to secure the lower denture and the existing denture would need to be fitted to accommodate the implants. The Plan denied your request. The Plan says the services 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 the modification of removable prosthesis (D5875), surgical implant placement (D6010), surgical access to an implant body (D6011) and custom fabricated abutment (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and comprehensive oral evaluation provided on April 28, 2021.
You asked the Plan to pay for the panoramic x-ray and comprehensive oral evaluation. You say that your dentist retired in the middle of the pandemic and records could not be sent to the new dentist. You say that the new dentist denied the cleaning without the x-ray and you wanted your teeth cleaned. The Plan denied your request. The Plan says the Plan has already issued reimbursement for a complete series of x-rays and a comprehensive oral evaluation.
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 also have a maximum benefit of one complete series x-ray every five years and one comprehensive oral evaluation every three years. The Plan paid for the intraoral complete series x-ray and comprehensive oral evaluation provided on February 18, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and comprehensive oral evaluation provided on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for two (2) rechargeable hearing aids (V5299) provided on March 29, 2021.
You asked the Plan to reimburse you for hearing aids. You say that you thought you would get reimbursed, and you did not know that this may be your copayment. You also say you did not know which brand would decide the copayment amount you would have. The Plan denied your request. The Plan says this specific hearing aid is not part of the Plan's formulary and is not part of the copayment structure.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that you are covered for up to 2 hearing aids per year, 1 hearing aid per ear. You pay a copayment for each hearing aid, and the copayment amount depends on the type of hearing aid purchased.
We looked at your review, the file, and the Plan's rules. The EOC confirms you pay a copayment depending on the type of hearing aid purchased. The records show that you purchased a hearing aid that is not part of the copayment structure. Please note, the Plan will reimburse you an additional $50 per hearing aid, leaving a remaining balance of $1,150 per hearing aid, as a courtesy. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for two (2) rechargeable hearing aids (V5299) provided on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services rendered on October 8, 2020.
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 procedure code 75716 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 75716 (radiological supervision and interpretation of bilateral extremity angiography) and 37227 (endovascular revascularization). Code 75716 is a column II code with a modifier indicator of 1 when billed with column I code 37227. Code 75716 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the radiology services rendered on October 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
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 the step therapy requirement is not 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 these services. Our reviewer says that the enrollee has Crohn's disease. She has not tried and failed the Plan's required drugs, Remicade or Inflectra and Stelara. The records do not support that the required drugs would be contraindicated or less effective; therefore, Entyvio is not reasonable or medically necessary. Our physician reviewer found 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 Entyvio.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021 to March 23, 2021.
You asked the Plan to pay for home health services. 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an invalid type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021 to March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that continuing physical therapy will continue you on the positive path you are on and your physical therapist is in support. You say that you don't have the luxury to wait for a long appeal process and you will regress. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have plateaued with therapy. and further skilled therapy is not likely to achieve any significant improvement in your symptoms or functional status. Our reviewer says that further utilization of the home exercise program is more appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.
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 self-administered drugs are not 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 pre-approve Restasis.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns - porcelain fused to predominantly base metal (D6751) and pontics - porcelain fused to high noble metal (D6240) provided January 21, 2021.
You asked the Plan to pay for the retainer crowns and pontics. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your 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 retainer crowns - porcelain fused to predominantly base metal (D6751) and pontics - porcelain fused to high noble metal (D6240) provided January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 30, 2021 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that this enrollee resides in a nursing home where the treating provider renders acute visits to the nursing home. You also say that under traditional Medicare, these claims would not need authorization. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider. 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 subsequent nursing facility care provided on April 30, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy and abdominoplasty (15830, 15847).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover abdominoplasty or panniculectomy for the following indications as it is considered not medically necessary: Repairing abdominal wall laxity or diastasis recti. We looked at the file and Medicare rules. The procedure is requested for the treatment of diastasis recti. Medicare does not cover abdominoplasty or panniculectomy for treating this condition. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy and abdominoplasty (15830, 15847).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FluidFlow amniotic liquid allograft (Q4206).

You asked the Plan to pre-approve FluidFlow amniotic liquid allograft. You say that this request is medically necessary. The Plan denied your request. The Plan says the request is not FDA approved or considered standard of care.

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 FluidFlow amniotic liquid allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 83-year-old woman has Left shoulder pain and decreased range of motion due to osteoarthritis. In this case, the requested therapy is not approved by the Food and Drug Administration (FDA). The request is 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 FluidFlow amniotic liquid allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve FluidFlow amniotic liquid allograft (Q4206).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage for a BiPAP (E0471).

You asked the Plan to pre-approve continued coverage for a BiPAP (E0471). You say that the requested continued coverage for a BiPAP (E0471) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued coverage for a BiPAP (E0471).

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 continued coverage for a BiPAP (E0471). Our reviewer says that the enrollee does not meet criteria for continued coverage for a BiPAP (E0471). Our physician reviewer found the record indicates that the enrollee used the machine greater than 4 hours a day 97% of the time. The provided record does not include a reevaluation note by the ordering physician. The elements of the continuing coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued coverage for a BiPAP (E0471) have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage for a BiPAP (E0471).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 (coagulation factor V) testing (81241).
You asked the Plan to pre-approve F5 testing. You say that you need this testing to find the cause of blood clots in your lungs. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients. We looked at the file and Medicare rules. The requested testing is non-covered except for pregnant patients. The submitted records do not indicate that you are pregnant. Based on this information, we decided that Medicare rules for coverage of F5 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F5 (coagulation factor V) testing (81241).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 70450-26 provided on May 21, 2021.
You asked the Plan to pay for code 70450-26. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450-26 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 70450-26 provided on May 21, 2021.
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 equipment needed is only offered at the acute rehabilitation facility. The Plan denied your request. The Plan says the requested admission to an 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 are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.

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.