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

We decided that the Plan does not have to pay for resin base partial denture (D5212), provided on March 15, 2021.

You asked the Plan to pay for resin base partial denture. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered.

Therefore, we decided that the Plan does not have to pay for resin base partial denture (D5212), provided on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 enrollee appears to be improving gradually, but still requires additional short-term
acute services that can be safely administered at the current facility until treatment is complete and transfer to a
lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already
available at the current facility. There would be no clinical advantage in transfer to LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you were quoted 20% coinsurance for orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Cyclosporine modified (J7515).
You asked the Plan to pre-approve a tier exception for Cyclosporine modified. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Cyclosporine modified have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Cyclosporine modified (J7515).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits in your home (G0151).
You asked the Plan to pre-approve home health services. You say that the requested PT visits are medically necessary. The Plan denied your request. The Plan says the provided documentation does not show that the requested services are medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer says that the home health physical therapy (PT) visits is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has home health PT needs. The reviewer found that the enrollee is functioning at a level comparable with a lower level of care (i.e. outpatient therapy, HEP). Therefore, the reviewer found that ongoing home health PT services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Specifically, the file shows that the enrollee does not have home health physical therapy needs. Therefore, we decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits in your home (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110) and bitewings - four radiographic images (D0274) provided December 1, 2020.
You asked the Plan to pay for the periodic oral exam, dental cleaning and bitewing x-rays. You say that you should have been told prior to your appointment that the provider had opted out of Medicare. The Plan denied quest. The Plan says the requested services are not covered because the provider has opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodic oral exam, dental cleaning and bitewing x-rays when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110) and bitewings - four radiographic images (D0274) provided December 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the emergency room visit (99284) and the urgent care office visit (99203) provided on June 1, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $90 copayment for each Medicare-cYou have been asked to pay $145 which includes a $90 copayment for the Medicare-covered emergency room visit and a $55 copayment for the Medicare-covered urgent care provider visit rendered. 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 adjust the copayment for the emergency room visit (99284) and the urgent care office visit (99203) provided on June 1, 2021.overed emergency room visit. Additionally, you must pay a $55 copayment for each Medicare-covered urgent care provider visit.
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 is not medically necessary.
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 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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.reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 an office visit to be provided 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 surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown. You say that these services are medically necessary, and you need this implant. The Plan denied your request. The Plan says these services are not covered by 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 pre-approve a surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has 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 that 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 the services are medically necessary. Our physician reviewer found based on the medical records provided you do require the services (skilled nursing services for intravenous antibiotics) on 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the inserts are to reduce your need for invasive medical care. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records do not show that you suffer from diabetic foot disease or you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 more time to work on daily living situations. The Plan denied your request. The Plan says that you can continue to receive appropriate intensive rehabilitation services at the IRF until you are ready to safely return to the home or community-based environment.

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 that your condition does not meet Medicare criteria for SNF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) provided on June 3, 2021.
You asked the Plan to pay for the scalings and planings. You say that per your dental policy, periodontal maintenance is a covered service. The Plan denied your request. The Plan says this service is not a benefit under the 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 two periodontal scalings and root planings (D4341 x2) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for
tooth #3.
You asked the Plan to pre-approve the dental service. You say that this service should be covered. The Plan
denied your request. The Plan says porcelain fused to high noble metal crown is not listed as a covered service.
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 porcelain fused to high
noble metal crown not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.

You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed Gel-One, Orthovisc, Synvisc, Synvisc-One or Visco-3. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on May 12, 2021.
You asked the Plan to waive the copayment for the dermatology visit. You say that you shouldn't have to pay this copayment because the doctor couldn't find the mole and simply gave you a prescription for a cream that you couldn't apply. 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 $20 copayment for visits with a specialist.
You have been asked to pay a $20 copayment for the dermatology visit. The dermatology visit falls within the visits with a specialist benefit category. This copayment applies regardless of the outcome of the visit. 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 dermatology visit you had on May 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy.
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 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 radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it appears that the requested services were denied as the records do not describe the treatment plan. It is unclear, based on what was submitted for review, specifically what is being requested. In order for there to be a denial, a request must have been submitted for specific services, but the records do not describe this, and the consultation note does not describe this. Therefore, it cannot be determined that the services are medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy.