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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on October 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and panoramic x-ray. You say that you were assured that this provider would accept your insurance and you thought you would be covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan to verify benefits or provider status prior to services being rendered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on October 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the prefabricated abutment and abutment supported porcelain/ceramic 
crown. You say that the existing implants need to be restored with an abutment and crown. You also say that if 
it is not restored, it can lead to infection and bone loss over time. The Plan denied your request. The Plan says 
these services are not covered under your benefit 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 pre-approve a 
prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve a tooth extraction. You say that you would like the Plan to reconsider 
approval for this service as you are out of antibiotics and your gums are uncomfortable. You say that your 
dentist advised you should see an oral surgeon right away because the roots of your tooth are growing into your 
sinus cavity. The Plan denied your request. The Plan says services must be 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 Plans coverage rules apply in this case. The Plan covers a tooth 
extraction when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a tooth extraction have not been met. Therefore, we decided that the Plan does not have to pre-
approve a tooth extraction (D7210) provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 18, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from February 18, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 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 inpatient psychiatric care from 
February 18, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of February 18, 2022, forward. Our physician reviewer found you 
did not require inpatient mental health treatment beyond February 18, 2022, as you were not a danger to 
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve your condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from February 18, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 18, 
2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested Botox. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet criteria for the requested Botox. Our physician reviewer found the record indicates that 
the enrollee has cluster headaches. The record does not document the presence of a covered indication for the 
requested service.  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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 8, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not order the ambulance. The Plan denied your request. The Plan says Original Medicare does not cover 
ambulance services if you are not transported. The Plan also says that you were not transported by the 
ambulance, and this claim processed correctly according to your benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 8, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service with no transport (A0998), provided
on September 15, 2021.
You asked the Plan to pay for the ambulance service with no transport. You say that the service was medically
necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 15, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance service with no transport (A0998),
provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on September 10, 2021, to October 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the acupuncture services. You say that the services were for pain management and the treatments have effectively lessened the pain. The Plan denied your request. The Plan says the provider was 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on September 10, 2021, to October 22, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6252) provided on September 28, 2021.
You asked the Plan to pay for the pontic. You say that you believe this procedure is covered as originally determined in July 2020. You also say that you noticed that the type of service numbers listed in July 2020 and most recently in September 2021 are different numbers. The Plan denied your request. The Plan says this service is not a covered benefit under 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 pontic (D6252) provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketamine infusion.
You asked the Plan to pre-approve Ketamine infusion. You say that the requested Ketamine infusion is medically necessary. The Plan denied your request. The Plan says the requested Ketamine infusion 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 Ketamine infusion. Our reviewer says that the requested Ketamine infusion is not medically necessary. Our physician reviewer found the review has determined that the requested use of Ketamine is not FDA-approved for the enrollee's diagnoses. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve Ketamine infusion.
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. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found it is not clear that you can participate in at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. The documentation does not support that there is a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 21, 2021.
You asked the Plan to pay for the core buildup. You say that you believe that the maximum for your quarterly max has not been met. The Plan denied your request. The Plan says the maximum allowed for your quarterly maximum has been met.
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 Plan offers a $50.00 allowance for covered comprehensive dental services every quarter. The record shows that you met the quarterly benefit on September 21, 2021 and your quarterly dental allowance for this quarter has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on September 21, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0429) provided on October 14, 2020.
You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that this transfer was done prior to the enrollee's admission to hospice. You also say that the enrollee was not admitted to hospice until after the ambulance trip. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0429) provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on May 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the test is a covered service and that you are a network provider. The Plan denied your request. The Plan says no prior authorization was obtained.
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 requested provider in this case is not a network provider with the Plan. 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on May 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-rays (D0230 x 2), scaling and root planing (D4342 x 3), and localized delivery of antimicrobial agents (D4381 x 2) provided from August 25, 2021, to September 1, 2021.
You asked the Plan to pay for the dental services. You say that you were not aware that these services were not covered. You say that these services have been covered in the past. You also say that you feel you should not be responsible for these bills. The Plan denied your request.
The Plan says periapical x-rays are not listed as covered services. The Plan says that scaling and root planing is not listed as a covered service. The Plan also says localized delivery of antimicrobial agents is not listed as a covered service either.
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 services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-rays (D0230 x 2), scaling and root planing (D4342 x 3), and localized delivery of antimicrobial agents (D4381 x 2) provided from August 25, 2021, to September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on October 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the records dated October 1, 2021, 
document diagnoses of breast cancer and adenoid cystic carcinoma, with metastatic carcinoma to bone for this 
enrollee. She is tolerating Olaparib without issue. The documentation does not support that the enrollee is 
untreated for the primary cancer being tested or is not responding to treatment. The documentation is 
insufficient to demonstrate that Guardant360 testing was medically reasonable and necessary for 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 testing rendered on October 11, 2021.  
 
Local Coverage Determination (LCD) L38168 referenced by the Plan is not valid for Part B Medicare for 
California where the single-source test was performed and was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2393, D2394) provided on September 16, 2021.
You asked the Plan to pay for the dental services. You say that you had 2 fillings done. You say that the provider does not do silver fillings without the protective coating. You also say that you feel that the full amount should be paid for the fillings. The Plan denied your request. The Plan says the claim was processed correctly. The Plan says posterior composite restorations are paid at the rate of an amalgam. The Plan also says you are responsible for the difference in cost.
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 and composite restorations are covered, the Evidence of Coverage clearly states that they are paid at the rate of an amalgam.
The record also states that you are responsible for the difference. Therefore, we decided that the Plan does not have to pay for the fillings (D2393, D2394) provided on September 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
You asked the Plan to pre-approve bone marrow aspirate. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of your health problem.
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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in spinal fusion surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 3, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider did not do anything and it was just a follow up visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for each visit with a specialist. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on September 3, 2021.