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

We decided that the Plan does not have to pay for the intraoral x-ray provided on June 3, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that it has been two years since you had any dental work done and you expected insurance to cover your services. You say that the service was really needed and are asking for the denial of payment to be reversed. The Plan denied your request. The Plan says the service 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. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve ventilator. You say that the enrollee would benefit from a ventilator rather than bi-level positive airway pressure (BiPAP) due to failure of benefit from BiPAP. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not have a qualifying diagnosis for a ventilator and a ventilator used to deliver support set in average volume assured pressure support (AVAPS) mode could be provided by a bi-level positive airway pressure (BiPAP) device.

The Plan must follow Medicare rules. Medicare rules say that a ventilator used to provide positive airway pressure therapy is not covered, regardless of the illness treated by the device. 

We looked at the file and Medicare rules. The requested ventilator is not covered by Medicare for positive airway pressure therapy. The Plan says that they would consider approval of a bi-level positive airway pressure (BiPAP) device upon request, and that this device would significantly reduce the enrollee's out-of-pocket expenses compared to a mechanical ventilator. Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH care
have not been met.
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 that the enrollee is not medically stable at this time. The enrollee continues to receive
acute care services and these have not been denied. The medical record does not indicate that the enrollee
requires services that the enrollee is not currently receiving but that would be available at the LTACH facility.
The elements of the coverage rules are not satisfied.
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival flap procedure (D4240).
You asked the Plan to pre-approve the gingival flap procedure (D4240). You say that your gums are causing
problems because of Lupus and you have no need for other dental services besides cleaning and this procedure.
You say that you need this procedure to correct the gum damage and the decision should be reconsidered. The
Plan denied your request. The Plan says the service 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. Therefore, we decided that the Plan does not have to pre-approve the
gingival flap procedure (D4240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the stationary oxygen tank (E0424)

You asked the Plan to pre-approve the stationary oxygen tank (E0424). You say that the item is medically necessary. The Plan denied your request. The Plan says the item 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stationary oxygen tank (E0424) have not been met. Therefore, we decided that the Plan does not have to pre-approve the stationary oxygen tank (E0424)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan (71271) for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that your doctor feels you need the requested procedure to ensure no cancer findings since you had been an avid smoker for years. The Plan denied your request. The Plan says rules for coverage for the requested procedure have not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section. We reviewed the file and the Medicare rules. We find that your tobacco smoking history is not clearly documented in the case record in terms of pack-years. Additionally, you quit smoking over 15 years ago.
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan (71271) for lung cancer screening.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 18, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the out-of-network charges because this was an emergency situation and there was no time to check if the provider was in-network. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for ambulance services. 

The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you are requesting to qualify for supplemental benefits. The Plan denied your request. The Plan says you do not meet the criteria to receive the Special Supplemental Benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the abdomen.

You asked the Plan to pre-approve an MRI of the abdomen. You say that this imaging service is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage criteria for the requested procedure have not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the abdomen. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee had a computed tomography (CT) scan in June 2021 that showed an indeterminate lesion. A letter from the ordering physician indicates an MRI was subsequently performed but is not included in the case file. The record provided does not establish the medical necessity or reasonableness of the requested service. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve a portable ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.

The Plan must follow Medicare rules. The rules say that there must be enough detailed information in the medical record to justify the decision to use a ventilator or a BiPAP device. 

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 portable ventilator. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. The Plan has indicated such a device is coverable. The elements of the coverage criteria are not satisfied.

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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinic visit provided on July 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the clinic visit. You say that the service was medically necessary. 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 service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the clinic visit provided on July 13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous peripheral nerve stimulator.

You asked the Plan to pre-approve peripheral nerve stimulator. You say that the enrollee needs this to treat his chronic intractable pain. The Plan denied your request. The Plan says the denial of authorization for use of this device is correct, because this is not generally accepted by the medical community.

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 peripheral nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational as there is not enough long-term data on outcome and complications. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontics (D6241 and D6245).

You asked the Plan to pre-approve the pontics (D6241 and D6245). 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 pre-approve the pontics (D6241 and D6245).
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 it is not safe to discharge home and you need SNF care. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 the medical record does not indicate that the enrollee requires services that he is not
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve molecular pathology procedure level 7 identified with code 81406.
You asked the Plan to pre-approve molecular pathology procedure level 7. 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 molecular pathology services are 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 molecular pathology procedure level 7. 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 a diagnosis of Myotonic muscular dystrophy. The enrollee has a normal creatine phosphokinase and the enrollee's electromyography demonstrated no myopathy. There is no clinical information documenting medical necessity for the requested lab test. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of molecular pathology procedure level 7 have not been met. Therefore, we decided that the Plan does not have to pre-approve molecular pathology procedure level 7 identified with code 81406.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay more for the eyeglasses provided on May 27, 2021.

You asked the Plan to pay more for the eyeglasses. You say that you cannot see why payment that is owed to you was withheld. You say that the benefit is $100 a year and you are owed more of a refund. The Plan denied your request. The Plan says that the claim processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $100 toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the eyeglasses have been met. Specifically, you have a $100 benefit, and the Plan did not pay $100 toward the eyeglasses. Therefore, we decided that the Plan has to pay up to $100 for the eyeglasses provided on May 27, 2021.

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 this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.

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 the enrollee does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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.