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

We decided that the Plan does not have to pre-approve a panoramic 3D dental x-ray.
You asked the Plan to pre-approve a panoramic 3D dental x-ray. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you are covered for panoramic x-rays once every 36 months under the Plan's supplemental dental benefit. The Plan says that you previously had a panoramic x-ray on October 26, 2021, which is less than 36 months ago.
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 contract clearly says that panoramic x-rays are only covered once every 36 months. The file shows that you received a panoramic x-ray on October 26, 2021, which is less than 36 months ago. Therefore, we decided that the Plan does not have to pre-approve a panoramic 3D dental x-ray
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need these services to get your strength
back up to 100%. The Plan denied your request. The Plan says these services are not medically necessary
because you had not had a change in function that needs daily 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing
service needs and you do not require skilled nursing or therapy services on a daily basis. The doctor also found
that you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing
facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: 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 the patient requires these services. The Plan
denied your request. The Plan says SNF admission is not medically necessary for the enrollee.
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 the enrollee does not have documented
skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is walking
household distances. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a
lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve neurology visit. You say that this is stressful for you and you do not think you should have to change doctors after going to the same one for 4 years. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network neurology specialist.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve neurology visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not approved by the Food and Drug administration (FDA) for the enrollee's diagnosis.
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 Prolia. Our reviewer says that the request for Prolia is not medically necessary. Our physician reviewer found there is no documentation that the requested use of Prolia is Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. The reviewer found that the enrollee's bone density scan shows osteopenia and not osteoporosis. The reviewer found that here is an off label use for Prolia for osteoporosis prophylaxis in postmenopausal women but available records do not show that the enrollee is taking 1,000 mg of calcium daily as is recommended for Prolia use. Therefore, the reviewer found that the request for Prolia cannot be approved at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Specifically, the file does not indicate that the enrollee is taking 1,000 mg of calcium daily as recommended for Prolia use. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had in your doctor's office on May 11, 2021.
You asked the Plan to waive the copayment for the EKG. You say that you had this service in your primary care provider's office, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for outpatient diagnostic tests. You have been asked to pay a $10 copayment for the EKG. The EKG falls within the outpatient diagnostic tests benefit category. This copayment applies regardless of the location where you receive this test. 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 electrocardiogram (EKG) you had in your doctor's office on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be performed by a periodontist.
You asked the Plan to pre-approve the dental service. You say that your general dentist was not able to complete a deep cleaning due to having gum disease. You also say that your gums were too sensitive and would need to be done by a periodontist. The Plan denied your request. The Plan says dental services performed by a periodontist 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services to be performed by a periodontist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be performed by a periodontist
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that you have reached reasonable expectations for improvement and is medically stable.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from December 14, 2021, forward were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that you do appear to require inpatient mental health treatment beyond the date in question as you remain uncooperative and aggressive. Active treatment was taking place. The services are reasonably expected to improve your condition or for the purpose of diagnosis. Although you were not shown to be a danger to yourself or others and you were not showing any auditory or visual hallucinations, you have been uncooperative/non-compliant with treatment. You were showing acute threats the safety. Therefore, the requested continued services are medically reasonable and 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 continued services have been met. Therefore, we decided that the Plan has to pre-approve continued inpatient psychiatric services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 you need rehab to function on your own. The Plan denied your request. The Plan says it is not reasonable to expect you to take part in 3 hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the acute care hospital for multiple fractures after a motor vehicle accident. Your medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker.
You asked the Plan to pre-approve the requested walker. You say that the enrollee cannot safely use a standard walker. The Plan denied your request. The Plan says medical need for a heavy-duty walker has not been met.
The Plan must follow Medicare rules. Medicare rules say that walkers are only covered under certain medical indications.
We looked at the file and Medicare rules. The records do not show that the enrollee weighs more than 300 pounds. Based on this information, we decided that Medicare rules for coverage of the requested walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker
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 the enrollee needs SNF care because you are concerned with her balance. You stated that she needs to continue to get stronger to be able to walk using a walker and become more stable on her feet. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no identifiable skilled nursing service needs. In addition, the enrollee does not require skilled nursing or therapy services on a daily basis. Finally, our doctor found that this enrollee does not meet Medicare's severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99284) provided November 14,
2020.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim cannot be paid 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.
We find that CPT code 99284 is not supported in the medical record. Specifically, the same physician group
already billed an evaluation and management service (99285) for the same date of service for this patient.
Based on this information, we decided that Medicare rules for coverage of the emergency room services have
not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99284)
provided November 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dermatology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the dermatology visit. You say that you have a rare condition, and the out-of-network provider is the only provider who specializes in your condition. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the dermatology visit to be provided by an out-of-network (OON) provider.
Your complaint about the Plan's unprofessionalism 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 beneficiary does not require skilled
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045) provided June 14, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim is a duplicate.
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 71045 is not supported in the medical record. Specifically, the records show 2 x-rays
were performed. The plan has already paid claims for 2 x-rays. The additional claim is a duplicate. Based on
this information, we decided that Medicare rules for coverage of the radiology services have not been met.
Therefore, we decided that the Plan does not have to pay for radiology services (71045) provided June 14,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided August 3, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this service is non-covered, and the order was not signed by the treating
physician.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The order for this testing was not signed by the physician treating this
beneficiary. Based on this information, we decided that Medicare rules for coverage of the lab services have
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided
August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 4 and 14.
You asked the Plan to pre-approve the endosteal implants. You say that you have a $5,000 comprehensive dental benefit, and the procedure is approximately $3,000. You also say that you have no problem paying the difference, but the amount is too high to pay alone. The Plan denied your request. The Plan says implants are only covered for members who are completely edentulous (without teeth) and the implants would be to retain (hold) a complete denture. The Plan also says that the x-rays of the maxillary arch show evidence of natural teeth.
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, dental implants are to hold a complete denture for members who are completely toothless in an arch. The dental x-ray provided shows that you still have natural teeth in the maxillary arch, and these implants cannot be covered. Therefore, we decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010) for tooth #'s 4 and 14.