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

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on September 9, 2021.
You asked the Plan to pay for the core buildup. You say that you would like this service to be approved. The Plan denied your request. The Plan says this service is not covered by 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 core buildup, including any pins when required (D2950) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental filling you had on August 2, 2021.
You asked the Plan to pay for the dental filling. You say that this repair was done because you broke your tooth while brushing your teeth. You do not believe that the frequency limitation should apply. The Plan denied your request. The Plan says you are only covered for two fillings per calendar year, at 50%. The Plan says that you already received covered fillings on May 6, 2021, and July 13, 2021, so you have exhausted your benefit for the 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 requested items or services are not
among those covered under this benefit. Your Plan only covers two fillings/restorations per year, and you have
already received two. This applies even if additional fillings/restorations are needed due to unexpected tooth
breakage. Therefore, we decided that the Plan does not have to pay for the dental filling you had on August 2,
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services.
You asked the Plan to pre-approve additional home health services. You say that this patient has not yet met
goals and is debilitated due to chronic diagnoses. The Plan denied your request. The Plan says additional home
health visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our
reviewer says that additional home health services are not medically necessary. Our physician reviewer found
the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or
services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain
the patient's condition and/or prevent deterioration. There is no evidence of enteral feedings, complex wound
care, or other skilled nursing need. The patient has had education on diabetes and pain management.
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 home health services have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable oxygen system (E0431).
You asked the Plan to pre-approve the portable oxygen system. You say that you need this item. The Plan
denied your request. The Plan says based on your documentation the request is not for stationary equipment but
for portable equipment and there is no documentation of your participation/enrollment in a clinical trial
approved by CMS.
The Plan must follow Medicare rules. Medicare rules say that only a stationary gaseous oxygen system (E0424)
and related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a
clinical trial approved by CMS.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the portable oxygen system have not been met. Therefore, we decided that the Plan does not have
to pre-approve the portable oxygen system (E0431).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF services. You say that additional SNF services are needed. The Plan denied your request. The Plan says SNF services are no longer medically reasonable and necessary.
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 continued SNF services. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF
coverage. You do not have documented skilled nursing needs or skilled therapy needs. You appear to have
reached a plateau in function. Daily skilled services are not shown to be required to establish a maintenance
program or to prevent deterioration of your condition. The doctor says that your needs are custodial and, as a
practical matter, can be provided at a lower level of 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 continued SNF services have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) services.
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. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a femur fracture after a fall. His medical problems are stable. He does not require treatment by multiple therapies in an intensive rehabilitation therapy program.
While he has a need for physical and/or occupational therapy, there is no documentation of a need for an
intensive rehabilitation program. The complexity of the patient's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ankle-foot orthosis brace to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the ankle-foot orthosis brace. You say that the enrollee is over 85 miles from the nearest in-network provider. 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 record shows an in-network provider is located 20 miles from you. Therefore, we decided that the Plan does not have to pre-approve the ankle-foot orthosis brace to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon.
You asked the Plan to pre-approve the requested services. You say that there is swelling, inflammation, and bone loss. The Plan denied your request. The Plan says the benefit is limited to services performed by a participating general dentist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The file shows that a consult and extraction of tooth #18 were requested. We looked at the file, and Medicare rules. Your plan contract shows that covered services must be performed by a participating general dentist. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve Eliquis tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Eliquis tablets are not covered under the enrollee's Medicare Part B benefit.
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 Eliquis tablets.
Benefits for Eliquis tablets 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after December 16, 2021.
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before December 16, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after December 16, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of a new patient (99201) and x-ray exams of the teeth (70300) provided on April 6, 2021.
You asked the Plan to pay for the office or other outpatient visit and x-ray exams of the teeth. You say that you were advised to pursue this claim under your medical insurance, as your teeth were fine before the accident and it was the accident that caused your teeth to be displaced. The Plan denied your request. The Plan says Medicare generally will not pay for dental services.
The Plan follows Medicare rules. Medicare rules say that Medicare generally does not cover dental services. The Plan follows the same rule. 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 office or other outpatient visit and x-ray exams of the teeth. Our reviewer says that these services were not medically necessary. Our physician reviewer found in this instance, despite the injury causing the non-displaced fracture of the maxilla which of itself did not require fixation, the treatment was primarily for stabilization of the teeth and not for a medical condition. As the primary treatment was not for a medical condition, the treatment rendered did fall under the dental exclusion of Section 150 of Medicare and as such would not qualify for coverage.
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 office or other outpatient visit and x-ray exams of the teeth have not been met. The services you are asking the Plan to pay for 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 pay for the office or other outpatient visit for the evaluation and management of a new patient (99201) and x-ray exams of the teeth (70300) provided on April 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on September 8, 2020.
You asked the Plan to pay for the physical therapy services. You say that the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on September 8, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial dentures.
You asked the Plan to pre-approve dentures. You say that you need your partials redone. The Plan denied your request. The Plan says the service exceeds the maximum allowed.
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.
The file shows that partial upper and lower dentures were requested. We looked at the file, and Medicare rules. The requested services were last received on August 7, 2019. Your plan only covers partial dentures once every five plan years. Based on this information, we decided that the Plan's rules for coverage of dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve partial dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compressor to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the pneumatic compressor. You say that the other providers do not provide this equipment. 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. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compressor to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection you received on October 29, 2020.
You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you have had these procedures in the past and only had to pay an office visit copayment. The Plan denied your request. The Plan says it has waived the copayments for the arthrocentesis procedures, but you are still responsible for the coinsurance for the Synvisc injection
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Synvisc injection. The Synvisc injection falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Synvisc injection you received on October 29, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive dental services.
You asked the Plan to pre-approve dental services. You say that you are having a hard time chewing. The Plan denied your request. The Plan says the 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. The file shows that a post and core, retainer crown, and pontic were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve comprehensive dental services
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 enrollee is at high risk of readmission due to his multiple comorbidities. The Plan denied your request. The Plan says the enrollee can safely receive care in another setting.
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 physician reviewer found that the enrollee was admitted to the acute care hospital with confusion, worsening kidney function, and an abnormal blood count. His hospital course was complicated by blood clots and infection. The enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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: 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 feel that 1-2 weeks in the facility would
improve your mobility, balance, and activities of daily living. The Plan denied your request. The Plan says you
do not require daily skilled services on an inpatient basis at the SNF level of care.
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 you have no identifiable skilled nursing
service or skilled therapy service needs. The doctor also found that you do not require skilled nursing or skilled
therapy on a daily basis. Finally, the doctor found that you do not meet severity of illness or intensity of service
criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick
You asked the Plan to pre-approve Repatha. You say that this will decrease the enrollee's risk for cardiovascular events in the future. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
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 Repatha SureClick
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.