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

We decided that the Plan does not have to pay for the intraoral complete series x-ray, comprehensive oral evaluation, 2D oral/facial photographic images and oral hygiene instructions provided on June 1, 2021.
You asked the Plan to pay for the intraoral complete series x-ray, comprehensive oral evaluation, 2D oral/facial photographic images and oral hygiene instructions. You say that you used an in-network provider from the website and the reason for the denial is invalid. You say that the Plan has paid nothing this year and the benefits have not been exceeded. The Plan denied your request. The Plan says reimbursement was previously issued for a complete series x-ray and comprehensive oral evaluation. The Plan also says that 2D oral/facial photographic images and oral hygiene instructions 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, 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 provided on January 29, 2019 and the comprehensive oral evaluation provided on February 26, 2020, which exhausted your benefits. The 2D oral/facial photographic images and oral hygiene instructions are not covered benefits. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray, comprehensive oral evaluation, 2D oral/facial photographic images and oral hygiene instructions provided on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (J3590).

You asked the Plan to pre-approve Aduhelm. You say that this drug is approved by the Food and Drug Administration (FDA) for treatment of Alzheimer's Disease. The Plan denied your request. The Plan says the requested drug is not medically reasonable or necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that Aduhelm is not medically necessary. Our physician reviewer found that the provided documentation indicates that the enrollee's presumed Alzheimer's disease has been more less stable since last visit. The reviewer found that the FDA-approved label states that Aduhelm is approved under accelerated approval based on reduction in amyloid beta plaques observed in patients treated with Aduhelm. The enrollee's case file does not contain documentation of amyloid beta plaques. Additionally, the FDA-approved Full Prescribing Information for Aduhelm (Adacanumab) requires a magnetic resonance imaging (MRI) be obtained prior to initiating treatment. The reviewer found that the provided MRI is from more than 1 year ago. The reviewer found that the provided documentation is insufficient to demonstrate that Aduhelm is medically reasonable of the enrollee in this case and is reasonably expected to be safe and effective for him.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Specifically, the file shows that does not contain
documentation of amyloid beta plaques or an MRI taken within the last year. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J3590).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation provided on
February 24, 2021, February 26, 2021, and March 5, 2021.
You asked the Plan to pay for non-emergency transportation. You say that the services occurred at the end of multiple hospitalizations when the enrollee was completely bedridden and unable to sit in a wheelchair for transportation back home. You say that these were not routine situations because the enrollee had no other way to leave the hospital and go back home, and the enrollee's life would have been endangered if they tried to transport any other way. The Plan denied your request. The Plan says routine transportation must be received through the Plan's transportation vendor to be covered under the benefits offered by the member's Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The file shows that the transportation was not provided by the Plan's transportation vendor. Based on this information, we decided that the Plan's rules for coverage of the transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency transportation provided on February 24, 2021, February 26, 2021, and March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81493) rendered by the out-of-network (OON) provider on August 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81493) rendered by the out-of-network (OON) provider on August 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services coded as 27266 provided on June 11, 2020.

You asked the Plan to pay for the surgery services. You say that you would like this claim paid based on the supporting medical documentation. The Plan denied your request. The Plan says there is a more appropriate CPT code to use in this case.

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, the CPT Code Manual definition of code 27266 is closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia. 

We asked our coder 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 surgery services. Our reviewer says that the billed code is not supported by the medical documentation. Our reviewer found the procedure report documents that the "Patient underwent conscious sedation after obtaining informed consent." Conscious sedation is not considered regional or general anesthesia per CPT code description requirements. There is a more appropriate code to report for this service. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services coded as 27266 provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), and bitewing x-rays (D0272) provided on March 17, 2021.
You asked the Plan to pay for the dental services. You say that the preventive benefit is a $0 copayment, 1 cleaning every 6 months, 1 limited exam every calendar year, 1 bitewing every calendar year, 1 full periodontal x-ray every 36 months. You say that the services you received are under your plan for a $0 copayment so they should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network 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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), and bitewing x-rays (D0272) provided on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for shoulder joint replacement surgery.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this service is available in-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. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for shoulder joint replacement surgery
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
.
You asked the Plan to pre-approve IRF care. You say that the standard timeframe of thirty (30) days will jeopardize the enrollee's life health, or ability to regain maximum function because the enrollee has been in the hospital for over a week now, the enrollee is obese (body mass index (BMI) of 42) and they are not progressing to the point where the enrollee is able to take care of themself at home where the enrollee lives alone so they are desperately needing physical therapy in order to be able to return home safely. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says average volume assured pressure support (AVAPS) mode could be delivered by bilevel positive airway pressure (BiPAP).
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have a diagnosis of COPD listed in the record, but there are no pulmonary function tests for confirmation. You were hospitalized with acute on chronic systolic heart failure. This is not an indication for a home ventilator. The ventilator is being prescribed for BiPAP, which is not covered by Medicare. The AVAPS mode of support can
be provided via BiPAP, at less cost. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99343), the home visits for the evaluation and management of an established patient (99348), and the subcutaneous tissue debridement (11042) rendered by the out-of-network (OON) provider from April 13, 2021, through April 20, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99343), the home visits for the evaluation and management of an established patient (99348), and the subcutaneous tissue debridement (11042) rendered by the out-of-network (OON) provider from April 13, 2021, through April 20, 2021.
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 March 31, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were coking
on food and you could not get the food to go up or down, which scared you to the point of calling 911. You say
if 911 is called in an emergency, the ambulance service should be covered by your insurance even though there
was not transport to the hospital. The Plan denied your request. The Plan says since there was no transport, the
ambulance charges are not covered.

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 March 31, 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 March 31, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for non-surgical management of a right humerus and right fibula fracture after a fall. The enrollee's medical problems are
stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cough stimulating device (CPT code E0482), for the enrollee.

You asked the Plan to pre-approve the device. You say that the enrollee is having trouble breathing and has multiple cases of aspiration as well as hospital stays. You state the enrollee is using Aerobika and it has been sufficient to keep their lungs clear. You state the enrollee has had multiple emergency room (ER) visits for aspiration pneumonia, Hemiparesis due to old head trauma, chronic respiratory issues with hypoxia, and chronic bronchitis. You state the enrollee has chronic aspiration events, needs more to improve their sinus secretion, they also have chronic obstructive pulmonary disease (COPD) with emphysema. The Plan denied your request. The Plan says the information does not show the enrollee has a neuromuscular disease; therefore, this means the Plan is not able to pay for the cough stimulating device.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. The enrollee does not have a neuromuscular disease. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the cough stimulating device (CPT code E0482), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relistor for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.

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 Relistor for the enrollee.

Benefits for this drug 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on January 12, 2021.

You asked the Plan to pay for the outpatient hospital services. You say that the patient was not in hospice on this date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on January 4, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D assay rendered on March 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D assay rendered on March 1, 2021.