Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter mitral valve repair (TMVR).
You asked the Plan to pre-approve TMVR. You say that the requested TMVR is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested TMVR.
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 TMVR. Our reviewer says that the enrollee does not meet criteria for the requested TMVR. Our physician reviewer found the record indicates that the enrollee has severe mitral regurgitation. The provided record does not document that the requested device is being used under Coverage with Evidence Development (CED) with the required team involvement. The elements of the coverage rule are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TMVR have not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter mitral valve repair (TMVR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, pulp vitality tests and cone beam CT capture provided on May 20, 2021.
You asked the Plan to pay for the limited oral evaluation, pulp vitality tests and cone beam CT capture. You say that the doctor referred you to this dentist for his opinion, special attention and to prescribe medication for pain. You say that you were required to pay on the spot with the understanding that you would be reimbursed. The Plan denied your request. The Plan says oral evaluations are only covered twice per calendar year and the pulp vitality tests and cone beam CT capture 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, you also have a maximum benefit of two oral exams per year. The Plan paid for an oral exam provided on January 6, 2021 and May 18, 2021, which exhausted your benefit. The pulp vitality tests and cone beam CT capture are not covered benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, pulp vitality tests and cone beam CT capture provided on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and oral
hygiene instructions (D1330) provided on March 16, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary and should be
covered by your dental benefit. The Plan denied your request. The Plan says they have agreed to pay for the
periodontal maintenance; however, the oral hygiene instructions and comprehensive periodontal evaluation are
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 evaluation (D0180) and oral hygiene instructions (D1330) provided on March 16,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you do not believe that your legs are strong enough, which puts you at risk for falls. You feel that specialized care and rehabilitation is needed. The Plan denied your request. The Plan says you can safely receive the services needed in the current inpatient rehabilitation facility (IRF) setting. At this time, transfer to a SNF is not medically reasonable and necessary.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a female with a medical history that includes recent lumbar laminectomy with post-operative complications and inpatient rehabilitation facility (IRF) stay. From a nursing perspective, the beneficiary received oral medications and had stable vital signs. Regarding rehabilitation services, the beneficiary received physical, occupational, and speech therapy in the acute hospital and IRF. The beneficiary was at a moderate assist level with bed mobility. The beneficiary required varying assist with daily living activities. She tolerated a regular diet and thin liquids. She had ongoing cognitive impairment. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily skilled therapy services requiring the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. This beneficiary does not meet severity of illness or intensity of service criteria for 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS ambulance service (A0427) provided April 15, 2021.
You asked the Plan to pay for the ambulance services. You say that both ambulance companies responded. You were transported by this provider as a paramedic was not needed. You believe that you should not be responsible for this invoice. The Plan denied your request. The Plan says you were not transported by this ambulance therefore the service is not covered under the Plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that there is no contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the ALS ambulance service (A0427) provided April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for an approved total knee replacement
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee would be better managed as an inpatient for this procedure. The Plan denied your request. The Plan says the surgery is approved, but there is no need for inpatient admission at this time.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician reviewer found This 69-year-old male was being treated for unilateral primary osteoarthritis of the right knee. The right total knee replacement was noted to have been approved. However, detailed documentation is not evident regarding a significant past medical history. The 8/11/21 initial history and physical sheet documents he is a non-smoker. Medical history has "no" circled for all conditions/diagnoses. Surgical history notes shoulder-rotator tears and 5th and 6th vertebrae. Medication listed: pantoprazole, quinapril, chlorthalidone, potassium, fenofibrate, atorvastatin, vitamin D3. Significant co-morbidities are not identified that would increase this enrollee's risk at peri-operative complications. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. The record does not show that the admitting physician reasonable expects that the patient's necessary hospital care will span two midnights. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for an approved total knee replacement.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for discission of secondary membranous cataract (66821) provided December 16, 2020.
You asked the Plan to pay for the procedure. You say that the enrollee's daughter told you the visit should be covered by the Plan because her mother was in hospice. Please process and pay this claim accordingly. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for discission of secondary membranous cataract (66821) provided December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the spinal procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says spinal process devices are considered investigational and are non-covered.
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 the spinal procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex device is experiemental. More research is needed to show safety and efficacy. 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 spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a Day Institute Program.
You asked the Plan to pre-approve the admission to a Day Institute Program. You say that you would like reconsideration because the member requires this admission to help perform activities of daily living. The Plan denied your request. The Plan says the member does not require speech therapy.
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 the admission to a Day Institute Program. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not reveal that the member requires speech therapy or is requires a Day Institute Program over standard outpatient physical and occupational therapy. Our physician reviewer found an admission to a Day Institute Program exceeds the patient's medical needs. 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 admission to a Day Institute Program have not been met. Therefore, we decided that the Plan does not have to pre-approve the admission to a Day Institute Program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5212) provided February 16, 2021.
You asked the Plan to pay for the lower partial denture. You say that you were told you had 100% coverage for dentures. The Plan denied your request. The Plan says this service is not covered when provided out-of-network. 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 lower partial denture when the services are medically necessary and reasonable. We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the lower partial denture have not been met. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5212) provided February 16, 2021.
Your complaint about potentially receiving incomplete information from a plan representative 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on December 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinusotomy (31295 and 31296).
You asked the Plan to pre-approve a sinusotomy (31295 and 31296). You say that the requested sinusotomy (31295 and 31296) is medically necessary. The Plan denied your request. The Plan says the requested sinusotomy (31295 and 31296) is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We 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 sinusotomy (31295 and 31296). Our reviewer says that the requested sinusotomy (31295 and 31296) is not medically necessary. Our physician reviewer found the enrollee suffers from recurrent acute sinusitis. The medical documentation does not support the diagnosis of chronic sinusitis, since there is no documentation of how long she has symptoms. There is no documentation on what symptoms she has. There is no evidence of sinusitis on the CT scan. Therefore, she does not meet criteria for a balloon dilation of her sinuses. The Academy supports use of a balloon sinuplasty in patients who have chronic sinusitis and evidence of changes on the CT scan. 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 sinusotomy (31295 and 31296) have not been met. Therefore, we decided that the Plan does not have to pre-approve a sinusotomy (31295 and 31296).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation (D9222) and subsequent 15-minute
increments (D9223 x3).
You asked the Plan to pre-approve deep sedation and subsequent 15-minute increments. You say that the
services are necessary. The Plan denied your request. The Plan says the requested services are 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 deep
sedation (D9222) and subsequent 15-minute increments (D9223 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotic.
You asked the Plan to pay for foot orthotic (L3040). You say that the office visit and x-rays should be covered. The Plan denied your request. The Plan says the arch support 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 pay for the foot orthotic.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 5, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that a Plan representative explained the benefits of choosing an in-network dentist, but assured you that bi-annual exams, cleanings, and x-rays would cost you nothing whether they were rendered in-network or OON. You also say that a maximum allowance was not clarified in the Plan's documents. The Plan denied your request. The Plan says this claim was processed and paid according to your plan benefits, the provider is OON, and you are responsible for the additional cost based on the terms of your contract. The Plan also says that you made no calls to the Plan prior to this date of 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, you are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 5, 2021 by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found there is no evidence that you are allergic to or intolerant of zoledronic acid. There is no evidence that you have tried and not responded to zoledronic acid. There is no documentation as to why zoledronic acid would not be expected to be safe and effective for you. Therefore, the requested Prolia 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on April 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on April 13, 2021.