Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches, which are included in the allowance of the power options.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed herself indicates that the enrollee can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower partial dentures.

You asked the Plan to pre-approve the upper and lower partial dentures. You say that you need a new set of dentures, as your previous pair broke. You say that you cannot properly chew your food because you have no teeth. You say that your stomach is enlarged, and your food is not being digested properly. The Plan denied your request. The Plan says your benefit for dentures has been exhausted for the 2021 calendar 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 benefit for dentures is limited to one set every five calendar years. The records show that you received coverage for dentures on April 12, 2017. This means that your benefit for dentures is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve upper and lower partial dentures.
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the present setting where he is currently receiving care. 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.

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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no need for daily skilled nursing or skilled therapy services. 
 
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 the admission. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy 
services on a daily basis. 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided from November 16, 
2020, to November 30, 2020. 
 
You asked the Plan to pay for the services provided. You say that the provider obtained an emergent care 
authorization for treatment. The Plan denied your request. The Plan says an invalid rate and procedure code 
combination was 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, the CPT Code Manual definition of code H0035 is mental health partial hospitalization, treatment, 
less than 24 hours. We find that CPT code H0035 is not valid for Medicare purposes. Medicare uses another 
code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the mental health services provided from November 16, 2020, to November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertebral axial decompression (S9090) provided May 5,
2021.
You asked the Plan to pay for the chiropractic services. You say that you are appealing this because you tried
everything to prevent surgery which they say would have been more than double than what you paid. The Plan
denied your request. The Plan says this service is not covered under the Plan benefits.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the vertebral axial decompression (S9090) provided May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus vaccination provided on February 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that the vaccine should be covered under the 
enrollee's current plan. The Plan denied your request. The Plan says the claim for services denied correctly. 
 
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 looked at the file and the rules. For those enrolled in a Medicare Advantage Plan in 2020 and 2021, claims 
should for COVID-19 vaccine administration should be submitted to Original Medicare through the Medicare 
Administrative Contractor (MAC). Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
coronavirus vaccination provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit (99203) you had on May 24, 
2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit (99203) you had on May 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits in the home.
You asked the Plan to pre-approve the PT visits. You say that the enrollee has a tri-level home and needs to be able to climb 15 stairs. You also say that the enrollee can only make it up to seven stairs due to their knee and getting off balance. The Plan denied your request. The Plan says the documentation provided does not show the condition is such that the enrollee is unable to perform therapeutic exercises without the supervision of a physical therapist.
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 the PT visits. Our reviewer says that the documentation does not support that the enrollee requires additional skilled rehab services to provide treatment that is medically necessary. Our physician reviewer found the enrollee does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Our reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She has had previous PT and should be independent with a home exercise program. Our physician reviewer also found that the requested home health services are not medically 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 the PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits in the home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network chiropractic services.  
 
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. 
The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 service 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 out of network services provided 
from April 28, 2021, to May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided June 19, 2021.
You asked the Plan to pay for the five remaining tooth extractions and upper and lower immediate dentures. You say that you were given an estimate that was lower than the amount you are being asked to pay. The Plan denied your request. The Plan says the Plan has covered dental services up to the annual maximum. The remaining 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 Plan covers tooth extractions and dentures up to the $1,500 annual maximum for dental services.
We looked at the file and Medicare rules. The Plan provided documentation showing that coverage has been provided for the year 2021 up to the $1,500 annual maximum. Therefore, we decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided June 19, 2021.
Your complaint about the actual cost of services being greater than the estimate you were provided 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency stretcher van mileage (T2049) provided on May 22, 2020.

You asked the Plan to pay for the non-emergency transport mileage. You say that these services were necessary, and payment has not been received. The Plan denied your request. The Plan says that they have agreed to pay for the non-emergent bus transportation, as the enrollee was directed to use this transportation by a Plan-contracted provider/facility, but the mileage is included in the fee and will not be paid separately.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for non-emergent bus transport services. 

While it is appropriate to bill mileage separately from the transport service, as it is not patient care equipment or first aid supplies, the services you have asked the Plan to pay for are generally not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the non-emergency stretcher van mileage (T2049) provided on May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says treatment can happen at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found you were involuntarily admitted to the acute inpatient psychiatric hospitalization on October 19, 2021 with Major Depressive Disorder, Recurrent, Severe without Psychotic Features. You were not expected to improve in a reasonable period of time beyond the dates in question, as you were not showing any dangerousness to self or others. There were no auditory or visual hallucinations, and no aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided March 17, 2021, and March 30, 2021.
You asked the Plan to pay for the limited oral exam and endodontic therapy. You say that you did not know until after the services were rendered that the provider was out-of-network. The Plan denied your request. The Plan says these services are not covered under your benefits. Additionally, the services were provided out-of-network and the enrollee signed a treatment plan showing $0 would be covered by insurance.
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 limited oral evaluation - problem focused (D0140), endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided March 17, 2021, and March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 24, 2020, to June 28, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee met the criteria for inpatient level of care due to gastrointestinal bleeding. The Plan denied your request. The Plan says the care needed could have been provided at a lower level.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was admitted following several episodes of coffee ground emesis. The enrollee was dehydrated and had a fast heart rate on examination. The record sufficiently documents that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 24, 2020, to June 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on January 25, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 items/services at issue in this appeal. 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 out of network physician services provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 3, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you do not agree with the denial you 
received, and the services should be covered because you have a broken tooth. The Plan denied your request. 
The Plan says emergency oral evaluation exams are covered once every 12 months. 
 
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 a limited oral 
evaluation once every 12 months.  
 
We looked at the file and Medicare rules. The records show that you received a limited oral evaluation on April 
28, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this information, we 
decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Therefore, we decided 
that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 3, 2021.