Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided on July 5, 2020, to July 8, 2020.
You asked the Plan to pay for the inpatient services. You say that you disagree with the DRG reassignment. The Plan denied your request. The Plan says that the principal diagnosis did not qualify for reporting.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and the rules. In this case, the records the Plan referenced in their decision do not match the records submitted in the case file. The case file does not include the mentioned emergency room physical exam, magnetic resonance imaging (MRI), computed tomography (CT) scan, or admission notes. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided on July 5, 2020, to July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the required criteria was not met.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of insulin use in the records provided. The criteria for this monitor are not met. It is unclear why a glucometer would not provide the blood glucose data sufficiently. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) and radiologic examination, spine, lumbosacral (72100) provided May 13, 2021.

You asked the Plan to pay for the chiropractic service. You say that in order for the doctor to properly treat you, he had to take an x-ray. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.

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 outpatient office visit (99203) and radiologic examination, spine, lumbosacral (72100) provided May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on April 30, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 services 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 the laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 12,
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.
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 physician services provided to the enrollee on
August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral x-ray (D0220),
and porcelain/ceramic crown (D2740) provided on April 7, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that there was a misunderstanding with the enrollee's
benefits, and you believed this provider was in-network. The Plan denied your request. The Plan says out-of-network
dental care is not covered. In addition, a limited oral exam is not a covered service, regardless of the
participation status of the provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover 
out-of-network dental care.

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 (D0140), intraoral x-ray (D0220), and porcelain/ceramic crown (D2740) provided on
April 7, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water
and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or
phone bill payments (debit card), home assistance services (repairs). You say that you have the chronic
conditions eligible to receive this benefit. The Plan denied your request. The Plan says the certification dated
September 10, 2021, documented that the enrollee has asthma but does not require intense care coordination,
and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that to be eligible for special supplemental benefits for the chronically ill, you must have
one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit
your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse
health outcomes and must require intensive care coordination.
We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to preapprove
special supplemental benefits for the chronically ill that includes transportation for non-medical needs,
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home
assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two restorative procedures (D2999 x2) and two bone
grafts at time of implant placements (D6104 x2).

You asked the Plan to pre-approve the restorative procedures and bone grafts. The Plan denied your request.
The Plan says these services are not covered under the enrollee's 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 two
restorative procedures (D2999 x2) and two bone grafts at time of implant placements (D6104 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) and accessory.
You asked the Plan to pre-approve continuous positive airway pressure (CPAP) and accessory. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that CPAP is only covered for certain indications. 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 continuous positive airway pressure (CPAP) and accessory. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has obstructive sleep apnea (OSA). While the documentation does support that the enrollee has a diagnosis/condition that meets criteria for the requested CPAP and accessory, there is no up to date compliance data in the available records showing that the enrollee is using the CPAP device greater than or equal to 4 hours a day for 70% or greater of the days during the measurement period as required by the LCD. Therefore, the enrollee does not meet criteria for the requested items. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous positive airway pressure (CPAP) and accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) and accessory.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096).
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the enrollee meets the requirements for coverage. The Plan denied your request. The Plan says this is not medically necessary.
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 a sacroiliac joint injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation on physical examination of tenderness to the sacroiliac joint. However, there is no documentation of sacroiliac provocative testing being completed with positive findings. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology, selective cellular enhancement technique
with interpretation (88112) rendered by the OON provider on June 16, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 service 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 this service. Therefore, we decided that the Plan
does not have to pay for the cytopathology, selective cellular enhancement technique with interpretation
(88112) rendered by the OON provider on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) for lung cancer screening.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that LDCT for lung cancer screening is covered for beneficiaries aged 55 to 77 years who meet specific criteria. We looked at the file and Medicare rules. The file shows that you are 80 years old. 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 pre-approve a low-dose computed tomography (LDCT) for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam image capture (D0364) and pulp vitality tests
(D0460) provided on April 26, 2021.

You asked the Plan to pay for the dental services. You say that these services were necessary, and you expected
them to be covered. The Plan denied your request. The Plan says these services are not covered by your dental
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. Therefore, we decided that the Plan does not have to pay for the cone
beam image capture (D0364) and pulp vitality tests (D0460) provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that a transfer and admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee is not medically stable to transfer to another level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound debridement services you
received at an outpatient hospital facility from April 21, 2021, to June 15, 2021.
You asked the Plan to waive the copayments for the wound debridement services. You say that you cannot
afford these copayments. The Plan denied your request. The Plan says you were charged these copayments
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 $225
copayment for outpatient surgery.
You have been asked to pay a $225 copayment for the wound debridement services. Wound debridement is
considered a surgical service, so the wound debridement services fall within the outpatient surgery 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 copayments for the wound debridement services you received
at an outpatient hospital facility from April 21, 2021, to June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that there is not documentation of your blood sugar levels.

The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor. Our reviewer says that the requirements for coverage of a continuous glucose monitor have been met. Our physician reviewer found the records show that you are being treated with metformin, lantus, and novolog, meeting the three or more daily insulin administrations requirement. The novolog has a correction factor that is used to adjust the dose at each meal, meeting the adjustment requirement, and you have been recently evaluated by your physician. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor.

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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the panoramic x-ray (D0330) provided on July 6, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you would like to appeal this service. The Plan denied your request. The Plan says that the benefit maximum for this time period or occurrence has been reached.
The Plan must follow Medicare rules. The rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The record shows that you received a panoramic x-ray (D0330), which the Plan denied for exceeding the frequency limitations. The 2021 Evidence of Coverage (EOC) says that dental x-rays are limited to 1, 2 or 4 x-rays per procedure; 1, 2 or 4 x-rays every 1 or 3 years depending on the type of x-ray. The EOC does not clearly state that you are only allowed 1 panoramic x-ray (D0330) either every 1 year or every 3 years. You reasonably believed this service would be covered because the frequency limitation for this procedure is not clearly noted in the 2021 EOC. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-ray have been met. Therefore, we decided that the Plan has to pay for the panoramic x-ray (D0330) provided on July 6, 2021.