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

 We decided that the Plan does not have to pre-approve a caries risk assessment and documentation (D0601), comprehensive oral evaluation (D0150), and periodontal scalings and root planings (D4341) of the upper left and upper right quadrants.  You asked the Plan to pre-approve the caries risk assessment and documentation, comprehensive oral evaluation, and scalings and planings. The Plan denied your request. The Plan says caries risk assessment and documentation is not a covered benefit. The Plan says that you have exhausted your comprehensive oral evaluation benefit. The Plan also says that the upper left and upper right quadrants do hot have four teeth that need treatment.  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 scalings and planings 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 scalings and planings. Our reviewer says that periodontal scalings and root planings (D4341) of the upper left and upper right quadrants do not meet coverage criteria. Our physician reviewer found the submitted code is designated for four or more natural teeth in a quadrant, not inclusive of implants. Our reviewer also found that the Plan criteria has not been met and a lesser code should be considered.  We looked at this physician's review, the file, and Medicare rules. Caries risk assessment and documentation (D0601) is not a covered benefit. The contract also says that comprehensive oral evaluation (D0150) is limited to once per 6 months. The record shows that the enrollee received a comprehensive oral evaluation (D0150) on October 11, 2021 and the enrollee's comprehensive oral evaluation (D0150) benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the caries risk assessment and documentation, comprehensive oral evaluation, and scalings and planings have not been met. Therefore, we decided that the Plan does not have to pre-approve a caries risk assessment and documentation (D0601), comprehensive oral evaluation (D0150), and periodontal scalings and root planings (D4341) of the upper left and upper right quadrants.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) (77373).  You asked the Plan to pre-approve radiation therapy. You say that the requested SBRT is medically necessary. The Plan denied your request. The Plan says that the requested SBRT does not meet criteria.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found for this enrollee, the plan is to treat a lung metastases. Other treatment options aside from SBRT for this enrollee include resection (with risks of surgery), hypofractionated image guided IMRT (likely less cost effective than SBRT) and palliative radiation. The treatment offered to the enrollee, SBRT to sites of oligoprogression, could be considered to be furnished in accordance with accepted standards of medical practice, acknowledging that the data supporting this treatment continue to arise.  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 been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) (77373).   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative approaches and is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that Vertiflex is helpful for the enrollee's condition.  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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for Extracapsular cataract removals provided on March 15, 2021, and August 16, 2021.  You asked the Plan to waive the copayment for the extracapsular cataract removals. You say that the services should be covered as you already paid $3000 upfront. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $390 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a $780 copayment for two extracapsular cataract removals ($390 x 2 = $780). Extracapsular cataract removals fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 Extracapsular cataract removals provided on March 15, 2021, and August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transthoracic echocardiography provided on August 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the transthoracic echocardiography. 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 transthoracic echocardiography provided on August 5, 2021, by an out-of-network (OON) provider.
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 LTACH care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on October 12, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that the services should be covered as the surgery failed. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $350 copayment for Outpatient hospital services.   You have been asked to pay a $350 copayment for an outpatient surgery. Outpatient surgeries fall within the Outpatient hospital services 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 an outpatient surgery provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical removal of an erupted tooth (D7210), consultation (D9310), and local anesthesia (D9215) provided on October 14, 2021.  You asked the Plan to pay for the dental services. You say that you were experiencing severe tooth pain. You say that you had your tooth extracted. You also say that you have a compromised immune system. The Plan denied your request. The Plan says the surgical removal of an erupted tooth, consultation and local anesthesia 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 surgical removal of an erupted tooth, consultation and local anesthesia are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical removal of an erupted tooth (D7210), consultation (D9310), and local anesthesia (D9215) provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the chest computed tomography (CT) scan you received on August 24, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you received a letter that this scan would be covered. The Plan denied your request. The Plan says this was not a denial.  Rather, because the allowed amount for this scan ($140.55) is less than your copayment obligation, you are responsible for the full allowed amount for this service.  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 $150 copayment for CT scans.   You have been asked to pay a $150 copayment for the CT scan. 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 chest computed tomography (CT) scan you received on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.  You asked the Plan to pre-approve a continuation of care with an OON provider. You say that the OON provider has been treating the enrollee since 2012. You say that a continuation of care is needed to maintain the enrollee's health. The Plan denied your request. The Plan says there are multiple network providers within a reasonable distance from the enrollee's location that can provide the services needed.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care.   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 continuation of care with an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee has a routine degenerative back condition. There is no need to stay with his out of network provider. The care may be safely transferred to an in-network spine doctor.  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 OON care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) provided on October 7, 2021.  You asked the Plan to pay for the periodontal exam. You say that you were dissatisfied with the care provided by an in-network provider, which caused you to seek care from another provider. The Plan denied your request. The Plan says this service is not covered by your dental benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) provided on October 7, 2021.   Your complaint about the care provided by a Plan-contracted dental provider 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 3, 2021, to September 5, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were over-sedated by mistake and that caused the need to stay in the hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $225 per day for days 1-6 for each inpatient stay.   The file shows that you were in the hospital from September 3, 2021, to September 5, 2021, but there is no copayment for the discharge date.  Therefore, you have been asked to pay $225 per day for the first 2 days of inpatient hospital services. The total for your stay is $450 ($225 copayment x 2 days = $450). The inpatient hospital services fall within the Inpatient Hospital Care 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 inpatient hospital services provided from September 3, 2021, to September 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627), provided on March 22, 2021.  You asked the Plan to pre-approve a seat lift mechanism. 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. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  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 seat lift mechanism. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not have severe arthritis of the hip and/or a neuromuscular disease. The records do not show that a seat lift is included in the treating practitioner's course of treatment, or that the item is not likely to: (a) effect improvement in the patient's condition; or (b) arrest or retard deterioration in the patient's condition. additionally, the records do not show that the patient is completely incapable of standing from a chair in the home.  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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627), provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for an ophthalmology office visit provided on September 13, 2021.  You asked the Plan to pay for office visit. You say that your physician requested this visit to redo a visual field test and compare the results, so this visit was performed for diagnostic reasons. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because you previously received a routine eye exam on March 1, 2021 and the Plan only covers 1 routine eye exam per year.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. You say that this visit was performed for diagnostic reasons. According to the claim billed by your treating physician, this visit addressed multiple non-routine diagnoses. Therefore, the claim billed by the provider supports that this visit was not a routine eye exam. Additionally, the Plan did not submit any medical records to show that this visit was routine in nature. The Plan did not submit any other rationale or evidence to support their denial of payment for this visit. Therefore, the Plan has not shown that its decision to deny payment for this visit is correct or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has to pay for an ophthalmology office visit provided on September 13, 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the enrollee needs the care to get better. The Plan denied your request. The Plan says that the services the enrollee requires can safely be received at a different setting.  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 the enrollee's 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 for the enrollee.