Persius/hicric huggingface dataset:
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 LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current 
level of care. 
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sandostatin LAR Depot (J2353), 30 mg.
You asked the Plan to pre-approve Sandostatin LAR Depot. You say that the requested drug is medically necessary. You also say that this will help to control the enrollee's bleeding. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Sandostatin LAR Depot. Our reviewer says that Sandostatin LAR Depot is not medically necessary. Our physician reviewer found Sandostatin LAR Depot is not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. The reviewer found that based on the medical records provided and the Medicare-approved major drug compendia, there is no documentation that the use of Sandostatin LAR Depot for iron-deficiency anemia and arteriovenous malformations, site unspecified, is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The reviewer also found that there is no documentation that the use of Sandostatin LAR Depot for iron-deficiency anemia and arteriovenous malformations, site unspecified is safe and effective and otherwise reasonable and necessary for this 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 Sandostatin LAR Depot have not been met. Specifically, the record shows that the requested drug is not approved by the FDA for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Sandostatin LAR Depot (J2353), 30 mg.
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 provided on June 2, 2021.
You asked the Plan to pay for code 70450. 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 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 provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a screening mammography and breast tomosynthesis provided on January 25, 2021.
You asked the Plan to waive the coinsurance for breast cancer screening. You say that the provider keeps telling you that you owe them more money, but you have paid the full amount owed. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 50% coinsurance for out-of-network breast cancer screening. The allowed amount of these services is $182.70, resulting in a coinsurance amount of $91.34.
You have been asked to pay 50% coinsurance for breast cancer screening. Breast cancer screening falls within the Breast Cancer Screening (Mammograms) 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 a screening mammography and breast tomosynthesis provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface and the resin-based composite - two surfaces received on June 17, 2021.
You asked the Plan to pay for the resin-based composite - one surface and the resin-based composite - two surfaces. You say that you feel this denial is unreasonable. The Plan denied your request. The Plan says the services received exceed your benefit limit.
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 services exceed this benefit. Review of the file shows that the Plan covers two restorations (fillings) per calendar year. The documentation shows that you previously received reimbursement for two fillings for the 2021 calendar year.
Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface and the resin-based composite - two surfaces received on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), a core buildup (D2950), and a filling (D2392) provided on May 10, 2021.
You asked the Plan to pay for a crown, a core buildup, and a filling. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the services at issue 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 a crown (D2740), a core buildup (D2950), and a filling (D2392) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical dental extraction identified with code D7210 provided on June 16, 2021.
You asked the Plan to pay for the surgical dental extraction. You say that the enrollee lives in a nursing home and was not able to see a dentist during the pandemic. The Plan denied your request. The Plan says the services received by the enrollee is 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, 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 surgical dental extraction identified with code D7210 provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded as S9348 provided
from March 12, 2021, to March 18, 2021.
You asked the Plan to pay for the home infusion therapy services. You say that you would like this claim
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim is not
eligible for payment under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9348 is not eligible for payment. Specifically, this code has a status indicator of "I"
which indicates this code is not valid for Medicare purposes. Based on this information, we decided that
Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided
that the Plan does not have to pay for the home infusion therapy services coded as S9348 provided from March
12, 2021, to March 18, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the SNF stay. We decided that the Plan does not have to waive the copayment for the SNF stay.
You asked the Plan to waive the copayment for the SNF stay. You say that you were told you would not have a copayment. You say you would have never stayed additional days if you knew you would have been charged. The Plan says that you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to reduce the copayment for the SNF stay.
The record shows the SNF copayment was applied to SNF days 22, 23, 24, and 25 in the amount of $745.12.
The Plan says you must pay a $745.12 copayment. However, based on the Plan contract, however, you cannot be asked to pay more than a $736 copayment. ($184 x 4 days = $736). Therefore, we decided that the Plan has to reduce the copayment for the SNF stay.
We also decided that the Plan does not have to waive the copayment for the SNF stay.
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 a $0 copayment per day, days 1 to 20 and a $184 copayment per day, days 21 to 100 for in-network SNF care. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and limited oral evaluation - problem focused (D0140) provided May 17, 2021.
You asked the Plan to pay for the panoramic x-ray, tooth extraction and problem focused exam. You say that you had a dental emergency, and you could not get an appointment with a network dentist soon enough. The Plan denied your request. The Plan says dental services are not covered when rendered by an out-of-network provider.
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 Plan covers the panoramic x-rays and tooth extraction when the services are rendered by a participating provider.
We looked at the file and Medicare rules. In this case the services were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction and panoramic x-rays have not been met. Though the Plan offers coverage in excess of Medicare coverage, the problem focused exam is not a covered service. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and limited oral evaluation - problem focused (D0140) provided May 17, 2021.
Your complaint about the length of time to get an appointment with a network provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385), provided on June 7, 2021.
You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.
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 a $400 copayment for same-day outpatient surgery in an Outpatient Hospital Facility. for Outpatient hospital services. You have been asked to pay a $400 copayment for same-day outpatient surgery in an Outpatient Hospital Facility. for the colonoscopy with lesion removal. the colonoscopy with lesion removal falls within the
Outpatient hospital services 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 copayment for the colonoscopy with lesion removal (45385), provided on June 7, 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus lab testing provided on May 19, 2021.
You asked the Plan to pay for the testing services. You say that each procedure had a different thing to do. The Plan denied your request. The Plan says procedures that represent overlapping services are considered mutually exclusive.
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 U0002 is 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc.
We looked at the file and the rules. The appropriate code to be reported is dependent upon the payer to which the claim is being submitted. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the healthcare common procedure coding system (HCPCS) Level II code, the HCPCS Level II code should be reported. CPT and HCPCS codes should not both be reported on the same claim. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus lab testing provided on May 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a polysomnography, sleep study diagnostic (95810), and a polysomnography titration for continuous airway pressure device (95811).
You asked the Plan to pre-approve the sleep study. You say that the sleep study is medically necessary based on the enrollee's diagnosis. The Plan denied your request. The Plan says repeat testing is not routinely indicated for the enrollees who are treated and have continued system resolution with a continuous positive airway pressure (CPAP) device.
The Plan follows Medicare rules. Medicare rules say that services performed for excessive frequency are not medically 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 the sleep study. Our reviewer says that the sleep study is not medically necessary. Our physician reviewer found the record indicates that the enrollee has sleep apnea and is using continuous positive airway pressure (CPAP) device. The record indicates that the enrollee has improved symptomatology. The record indicates that the enrollee is going to travel and wants a new CPAP device. The record does not indicate the current machine is not functioning properly. The elements of the 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 the sleep study have not been met. Specifically, the file does not show that the enrollee's current CPAP device is not functioning properly. Therefore, we decided that the Plan does not have to pre-approve a polysomnography, sleep study diagnostic (95810), and a polysomnography titration for continuous airway pressure device (95811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete dentures. You say that you need new dentures so you can eat vegetables and meat in order to obtain your nutrition health. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on September 3, 2019 and your complete maxillary denture (D5110) and complete mandibular denture (D5120)
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete mandibular denture. You say that your current denture is broken, and you had no control over it. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, complete mandibular denture (D5120) is limited to one procedure every five plan years. The record shows that you received a complete mandibular denture (D5120) on June 18, 2020 and your complete mandibular denture (D5120) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
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 these services are medically necessary. The Plan denied your request. The Plan says that records do not show that you require daily skilled nursing or rehabilitation services on a daily basis.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on November 17, 2020.
You asked the Plan to pay for pneumatic compression device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because a pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device is not covered for the purpose of prevention of venous thromboembolis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided on November 17, 2020.