Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health physical therapy services (G0151).
You asked the Plan to pre-approve the home health PT services. You say that you get stronger with the therapy and going up the stairs. You try to get around as much as you can, but you have to use a walker and your legs swell up. You feel you need a little more time. The Plan denied your request. The Plan says there is no evidence that continued physical therapy is reasonable or 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 the home health PT services. Our reviewer says that the enrollee does not meet the Medicare criteria for continued home health skilled therapy level of coverage. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. The enrollee has had extensive prior therapy and should be able to transition to an independent home program. Given the fact that he has had skilled therapy for 2 years and has persistent complaints and deficits the need for ongoing skilled therapy services is not supported. 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 home health PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of home health physical therapy services (G0151).
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on February 13, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee 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 medical services provided to the enrollee on February 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee has a brain arterial-venous malformation and brain mass. You state these have caused the enrollee's right-sided weakness. You state the enrollee is improving with physical and occupational therapy but cannot take care of themselves at home yet. The Plan denied your request. The Plan says the stay is not medically 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued intermittent services at a lower level of care. Although the enrollee made progress with therapy, the enrollee's functional improvement has plateaued, there is no indication that transfer to a SNF is required. The enrollee can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on May 17, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that the wrong CT scan was ordered, and
you should not have to pay for the physician's mistake. The Plan denied your request. The Plan says the claims
were processed correctly, and you are being charged the correct amount.
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 $225
copayment for advanced imaging.
You have been asked to pay the allowed amount of $171.66, which is less than the $225 copayment for a CT
scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral appliance therapy.
You asked the Plan to pre-approve the oral appliance therapy. The Plan denied your request. The Plan says treatment for Temporomandibular Joint Syndrome (TMJ) is excluded from coverage.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically 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 the oral appliance therapy. Our reviewer says that the coverage criteria is not satisfied. Our physician reviewer found that you have ear plugging issues and may also have sleep apnea as etiology of sleep disordered breathing. Our reviewer says that the device is used to protect dentition and TMJ is not the medical condition that is causing the symptoms. 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 oral appliance therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the oral appliance therapy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (TTE) with doppler,
complete, (93306) provided on April 9, 2021, by an OON provider.
You asked the Plan to pay for the ultrasound. You say that you are not always aware that prior authorization is
necessary prior to provided services as you are a 24-hour facility. You also say that you cannot deny medically
necessary services to the enrollee. The Plan denied your request. The Plan says prior authorization was not
obtained prior to the services being rendered to the enrollee. The Plan also says the services were not urgent or
emergent in nature.
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 referring provider is not a network
provider, or the enrollee's primary care physician (PCP). The Plan did not pre-approve the item/service at issue.
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that
the Plan does not have to pay for the transthoracic echocardiography (TTE) with doppler, complete, (93306)
provided on April 9, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22867, 22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary and clinically supported. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show that it is safe and effective.
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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22867, 22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have [e.g., to pay for ... to provide ... to waive the copayment for ... ] [complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
You asked the Plan [e.g., to pay for ... to provide ... to waive the copayment for ... ] [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like reconsideration because the testing was medically necessary. The Plan denied your request. The Plan says the member did not have any signs or symptoms to indicate these tests were medically necessary and the testing is not being used to manage or treat a specific medical problem or diagnosis.
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 [e.g., to pay for ... to provide ... to waive the copayment for ... ] [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have a personal or family history of malignancy. It is unclear how these results would impact his health 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 [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been met. Therefore, we decided that the Plan does not have [e.g., to pay for ... to provide ... to waive the copayment for ... ] [complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and implant supported crown (D6065) provided on June 23, 2021.
You asked the Plan to pay for the custom fabricated abutment (D6057) and implant supported crown (D6065). You say that you weren't informed implants weren't covered. You say that you were told you would receive partial payment for services you had done. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and implant supported crown (D6065) provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
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 records do not show the date or results of the first procedure.
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 under the Medicare guidelines, the request is not medically necessary, as the records show that you did
not have adequate pain relief from the first procedure. You had a procedure on the lumbar region on 8/27/21.
However, you reported no relief from that procedure, as reported in a post-procedure follow-up dated 9/13/21.
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 radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture (D9120), provided on February 25, 2021.
You asked the Plan to pay for the fixed partial denture. You say that the service was medically necessary. The Plan denied your request. The Plan says the serve is not a covered benefit.
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. Specifically, the service is not listed in the Plan's benefit chart. Therefore, we decided that the Plan does not have to pay for the fixed partial denture (D9120), provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass with gold crown (D2752) for teeth #8 and #9.

You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says these services exceed the benefit allowance.

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 crowns once every 60 months.

The files shows that a crown was last provided on July 26, 2019. This is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a white glass with gold crown (D2752) for teeth #8 and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to waive the sales tax ($15.59) charged by the provider for this equipment.
You asked the Plan to waive or reduce the cost of the equipment and the sales tax. You say that you do not believe the cost of this item is correct. The Plan denied your request. The Plan says while the coinsurance was adjusted to your contractual 20% cost share, the sales tax is a state law expectation and cannot be waived.
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 durable medical equipment. The Plan reduced to the cost share to your Plan contract coinsurance of $37.80. However, based on state and local laws for commercial purchases, sales tax cannot be waived. The provider is within their right and expected to charge sales tax. 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 sales tax ($15.59).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on April 13, 2021.
You asked the Plan to pay for the hearing aids. You say that you were informed that your plan was
reimbursable. You say that you do not want to return your devices. The Plan denied your request. The Plan
says the hearing aids were received out-of-network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are received from a network vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Specifically, the hearing aids were received from an out-ofnetwork
vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on
April 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing visits.
You asked the Plan to pre-approve the requested services. You say that continued therapy will help with mobility. The Plan denied your request. The Plan says there is no documentation of ongoing medical management requiring skilled nursing oversight.
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 requested services. Our physician reviewer found that the records do not show skilled nursing services are required to provide services in order to improve your condition, or to perform a maintenance program to maintain your condition or prevent deterioration. The records do not show that that you have unstable medical issues, complex wound care, new enteral feedings or other skilled nursing needs. You have been educated in medications, disease management, skilled teaching related to pain management, and wound prevention/management. Therefore, the requested 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic care (98941) provided on March 2, 2021, through March 22, 2021.
You asked the Plan to pay for the chiropractic care. You say that you would like reconsideration because visits from the same provider have been covered. The Plan denied your request. The Plan says the documentation submitted is insufficient to determine if a physician's order was given, h, the referring provider, how you came to this provider and/or whether the services are necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chiropractic care have not been met. Specifically, there is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the chiropractic care (98941) provided on March 2, 2021, through March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210) and dentures (D5110 and D5120), provided on January 19, 2021, and March 16, 2021.

You asked the Plan to pay for the extractions and dentures. You say that the service is medically necessary. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the services obtained are not listed in the Plan's benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for the extractions (D7210) and dentures (D5110 and D5120), provided on January 19, 2021, and March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Botox injections provided on April 1, 2021.
You asked the Plan to pay for the Botox injections. You say that you would like reconsideration because the
dentist was the only office available to render this service. The Plan denied your request. The Plan says the
billed service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only
when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for the Botox injections. Our reviewer says that
the documentation provided does not meet the criteria for coverage for the service. It was not documented that
a medical condition is the cause of the patient's TMJ dysfunction. Our physician reviewer found Bruxism was
indicated as a possible etiology. Splint therapy is commonly used for reduction of symptoms in these cases
along with exercise and soft diet.
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 Botox injections have not been met. Therefore, we decided that the Plan
does not have to pay for the Botox injections provided on April 1, 2021.