Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport provided on May 9, 2021.

You asked the Plan to pay for ambulance service, advanced life support, emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, advanced life support, emergency transport. Our reviewer says that the ambulance transport was medically necessary. Our physician reviewer found that the enrollee is a 67-year-old female with acute respiratory disease, shortness of breath, hypoxemia, asthma, Coronavirus infection, long-term drug therapy who was transported via ambulance. She was treated with dexamethasone for her Coronavirus related shortness of breath and given oxygen. The enrollee's vitals were stable upon transport from one hospital to another on 4L via nasal cannula. The presentation of shortness of breath and hypoxia requiring oxygen would qualify as meeting layperson criteria for emergency 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 ambulance service, advanced life support, emergency transport have been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, emergency transport provided on May 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you want a second opinion in regard to your post-poliomyelitis syndrome. 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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the 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 an implant (D6010), custom fabricated abutment (D6057), and abutment supported crown (D6059) for tooth # 8.

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says implant is not listed as a covered service. The Plan says that custom fabricated abutment is not listed as a covered service. The Plan says that abutment supported crown is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant, custom fabricated abutment, and abutment supported crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant (D6010), custom fabricated abutment (D6057), and abutment supported crown (D6059) for tooth # 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extractions (D7210) and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).

You asked the Plan to pre-approve the extractions and intravenous moderate (conscious) sedation/analgesia. You say that you have been told that knee replacement surgery cannot be scheduled until your teeth have been removed. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not purchase the additional dental supplemental 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. The extractions at request are needed prior to receiving your knee replacement surgery. Only extractions rendered to prepare the jaw for radiation treatments of neoplastic cancer disease are covered. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit, injection.

You asked the Plan to pre-approve Procrit, Injection, epoetin alfa, (for non-esrd use), 1000 units (J0885). You say that Retacrit is not yet available in multi dose vials. The Plan denied your request. The Plan says the enrollee has not tried and failed approved Retacrit.

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 Procrit, Injection, epoetin alfa, (for non-esrd use), 1000 units (J0885). Our reviewer says that the health plan's denial should be upheld. Our physician reviewer found there is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to why Retacrit would not be expected to be safe and effective for the enrollee. Therefore, the requested Procrit is not shown to be currently medically necessary and 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 Procrit, Injection, epoetin alfa, (for non-esrd use), 1000 units (J0885) have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit, injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for restorative procedure (D4212).

You asked the Plan to pre-approve the gingivectomy or gingivoplasty. You say that you have cracked teeth that cause you to bite yourself. You also say that you are in pain. The Plan denied your request. The Plan says gingivectomy or gingivoplasty 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for restorative procedure (D4212).
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 would like reconsideration because the admission is medically necessary. The Plan denied your request. The Plan says your rehabilitation needs do not require an intensive team for you to reach your functional goals.

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 there are no complex nursing or rehabilitation needs. There is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on May 12, 2021.
You asked the Plan to pay for physical therapy. You say that the appeal should be reviewed, and authorization should be provided. The Plan denied your request. The Plan says prior authorization for out-of-network services was required but not 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. Therefore, we decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simply Thick, a food thickening agent.

You asked the Plan to pre-approve Simply Thick. You say that you have difficulty swallowing. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for food thickeners. 

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Simply Thick, a food thickening agent.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit with a specialist provided on May 17, 2021.
You asked the Plan to waive the copayment for a telehealth visit with a specialist. You say that the doctor called you so you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $15 copayment for each specialist visit, including telehealth visits. The medical records show that you had a telehealth visit with a specialist on May 17, 2021. Therefore, you are responsible to pay the $15 copayment.
You have been asked to pay a $15 copayment for a telehealth visit with a specialist. A telehealth visit with a specialist falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a telehealth visit with a specialist provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival irrigation (D4921) and application of desensitizing medicament (D9910).
You asked the Plan to pre-approve the gingival irrigation (D4921) and application of desensitizing medicament (D9910). 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 gingival irrigation (D4921) and application of desensitizing medicament (D9910).
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 x2), two prefabricated abutments (D6056 x2), and two implant supported crowns (D6066 x2).

You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant supported crowns. You say that you need the implants in order to be able to eat properly. The Plan denied your request. The Plan says these services are not covered under your benefit package.

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 surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated abutments (D6056 x2), and two implant supported crowns (D6066 x2).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a pontic (D6245) for tooth #10, retainer crowns (D6740) for tooth #'s 9 and 11, and a fixed partial denture sectioning (D9120) for tooth #9.

You asked the Plan to pre-approve the pontic, retainer crowns, and fixed partial denture sectioning. You say that the enrollee's bridge was placed over 10 years ago. The Plan denied your request. The Plan says that the information does not say why a denture cannot be used to replace the enrollee's missing 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. The Plan covers the pontic, retainer crowns, and fixed partial denture sectioning when the services are medically necessary and reasonable. 

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 pontic, retainer crowns, and fixed partial denture sectioning. Our reviewer says that a fixed replacement bridge for the replacement of tooth #10 and bridge sectioning for removal of the current bridge are both medically reasonable and necessary Our physician reviewer found the current bridge is to be removed. Core buildup of teeth #'s 9 and 11 has been approved. Our reviewer found that the final restorations of tooth #'s 9 and 11 would be crowns since the present crowns are to be removed. Therefore, is would be the standard of care to use a pontic to replace the missing #10 instead of a removable partial denture. Our physician reviewer also found that the removal of the current bridge would involve the sectioning prior to removal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic, retainer crowns, and fixed partial denture sectioning have been met. Therefore, we decided that the Plan has to pre-approve a pontic (D6245) for tooth #10, retainer crowns (D6740) for tooth #'s 9 and 11, and a fixed partial denture sectioning (D9120) for tooth #9.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic (CT) colonography screening.
You asked the Plan to pre-approve CT colonography screening. 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 a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography (CTC) is non-covered. We looked at the file and Medicare rules. The requested services are not a covered benefit. Based on this information, we decided that Medicare rules for coverage of CT colonography screening have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic (CT) colonography screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210 x 12), and consultation (D9310) provided on May 21, 2021.

You asked the Plan to pay for the dental services. You say that your oral surgery was medically necessary as you had developed a severe infection. You say that you are on a fixed income. You also say that you cannot afford any extra expense. The Plan denied your request. The Plan says 2 extractions are covered per calendar year with a 50% coinsurance when performed in network. The Plan says that the frequency limit has been exceeded. The Plan also says that consultation 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 and extractions are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 4 extractions that you received on this date of service. Additionally, the consultation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 12), and consultation (D9310) provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 23, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you were not aware of the limitations for this service and you cannot afford to pay the charge. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on January 31, 2019 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820) and a bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the maxillary interim partial denture and bone replacement graft. 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 a maxillary interim partial denture (D5820) and a bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #19.

You asked the Plan to pre-approve the crown. You say that the enrollee needs a replacement crown. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, crowns are limited to one procedure per tooth every five plan years. The record shows that the enrollee received a crown (D2750) on tooth #19 on November 28, 2018 and the enrollee's crown benefit for tooth #19 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2335) for tooth # 24, and the filling (D2391) for tooth # 3 provided on May 26, 2021.
You asked the Plan to pay for the dental services. You say that you were transferred to this dentist because yours left in 2019. You also say that you lost your job in 2020. The Plan denied your request. The Plan says fillings are not listed as covered services.
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 fillings are not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2335) for tooth # 24, and the filling (D2391) for tooth # 3 provided on May 26, 2021.