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

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on June 1,
2021.

You asked the Plan to pay for the crown. You say that you do not understand why you owe this amount for the
crown. The Plan denied your request. The Plan says they have paid for part of the crown, but you have met
your benefit's maximum allowance and are responsible for the remaining cost.

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 can pay up to $1,500
per year for supplemental preventative and comprehensive dental services per year. You are responsible for any
amount over and above this allowance amount.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the Plan's
$1,500 annual benefit limit are not covered under this benefit. Records show that the Plan has paid the full
$1,500 allowance for you for supplemental dental care in 2021, including part of the cost of the crown in
question. The remaining cost exceeds the $1,500 limit. Therefore, we decided that the Plan does not have to
pay for the porcelain/ceramic crown (D2740) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 25, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that you have a periodontal maintenance every three months to keep infection down after having your gums cut back. You also say that you feel this service should be covered because your dentist recommended it. The Plan denied your request. The Plan says this service is a covered benefit, but you have exceeded the limits set in the subscriber agreement.

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, periodontal maintenance (D4910) is limited to once per 12 months. The record shows that you received a periodontal maintenance (D4910) on March 5, 2021 and your periodontal maintenance (D4910) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a three dimensional (3D) photographic image (D0351),
two crowns (D2740 x2), six core buildups, including any pins when required (D2950 x6), periodontal
maintenance (D4910), three pontics (D6245 x3), four retainer crowns (D6740 x4), and collection and
application of autologous blood concentrate product (D7910).

You asked the Plan to pre-approve the 3D photographic image, crowns, core buildups, periodontal
maintenance, pontics, retainer crowns, and collection and application of autologous blood concentrate product.
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
three dimensional (3D) photographic image (D0351), two crowns (D2740 x2), six core buildups, including any
pins when required (D2950 x6), periodontal maintenance (D4910), three pontics (D6245 x3), four retainer
crowns (D6740 x4), and collection and application of autologous blood concentrate product (D7910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - new/established patient (D0150), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided April 7, 2021, and the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided May 5, 2021 provided by an out-of-network (OON) provider.

You asked the Plan to provide additional payment for the comprehensive oral exam, dental cleaning, bitewing x-rays, limited oral exam and intraoral x-rays. You say that the enrollee was unaware that the dental office was OON and asked you to submit an appeal. The Plan denied your request. The Plan says the OON services were covered correctly.

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 comprehensive oral exam, dental cleaning, bitewing x-rays, limited oral exam and intraoral x-rays up to a certain amount when obtained OON. If the enrollee chooses to see an OON dentist, they might be billed for any amount greater than what the Plan pays. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan provided documentation that the full allowed amount was covered for the requested services. The enrollee is responsible for the remaining amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - new/established patient (D0150), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided April 7, 2021, and the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided May 5, 2021 provided by an out-of-network (OON) provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for atrial fibrillation and
cellulitis of the right leg. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient 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. There is not a reasonable expectation that this patient will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional bilateral two level radiofrequency ablations (RFA) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation indicates that this request would exceeds the limitations.
The Plan must follow Medicare rules. The rules say that no more than two radiofrequency sessions will be reimbursed per rolling 12 months. The file shows that two RFAs have been received in the last year, on 4/13/21 and 5/10/21. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional bilateral two level radiofrequency ablations (RFA) for the enrollee.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 is a 77-year-old female with a past medical history of mitral valve disease, atrial fibrillation, coronary artery disease and congestive heart failure who presented to the acute hospital on September 15, 2021.
Based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. In conclusion, there is no documentation that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve cataract surgery to be rendered by the out-of-network (OON)
provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says that there are in-network providers available to render the
requested service.
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 facility in this case is not a network provider with the Plan. However, the physician requested to
perform the surgery is a network provider with the Plan. The physician's office has indicated that this is the
only facility that can be utilized to perform the requested service. Since there is no network facility available at
which the network surgeon can provide covered services, the Plan must arrange for care to be provided at the
out-of-network facility. Therefore, we decided that the Plan has to pre-approve cataract surgery to be rendered
by the out-of-network (OON) provider.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive pharmacogenetic testing services provided on February 11, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says a panel constitutes a single procedural service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and the rules. If a single procedure is performed, only one CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenetic testing services provided on February 11, 2021.
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 documentation does not justify that you have medical complexity requiring medical supervision three times a week.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for Clostridium difficile colitis and acute kidney injury. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved and is no longer a threat to herself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as she does not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. This patient does not show any abnormal behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she does not have dangerousness to self or others but was compliant with her treatment. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on May 6, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on the date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. CPT code 76700 was billed with code 93976. The rules say that the billed services may be justifiable for the code combination. However, we find that CPT code 76700 was not billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - three surfaces, anterior (D2332) provided March 25, 2021.
You asked the Plan to pay for the filling. You say that you feel that if you have exceeded frequency limits it was an oversight on the Plan's part not yours and you should not be responsible for the cost. The Plan denied your request. The Plan says you have exceeded frequency limits for this 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. The Plan covers the filling twice per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that two fillings were previously covered on January 13, 2021. Based on this information, we decided that the Plan's frequency limit
for coverage of the filling has been exceeded. Therefore, we decided that the Plan does not have to pay for the
resin-based composite - three surfaces, anterior (D2332) provided March 25, 2021.
Your complaint about potentially receiving confusing or misleading information from the Plan or provider
about coverage and receiving a bill after services were rendered is not a valid appeal for medical coverage. This
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that you need the bone removed in your mouth in order to get dentures or a plate. 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 removal of torus mandibularis (D7473).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on April 28,
2021.
You asked the Plan to pay for the laboratory services. You say that the enrollee was seen by an in-network
physician with no control over the laboratory. The Plan denied your request. The Plan says this provider is outof-
network, the services were not referred by a network provider, and the services were not urgent or emergent,
nor were they approved in advance.
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 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 the laboratory services provided to the enrollee on
April 28, 2021.