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

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 16, 2021.
You asked the Plan to pay for a panoramic radiographic image. You say that the dental office tried to take the bitewing x-rays, but they were not able to get complete pictures of your mouth and the panoramic x-ray was needed for diagnostic quality. You also say that they wanted the panoramic x-ray to be reconsidered due to the extenuating circumstances. The Plan denied your request. The Plan says the panoramic x-rays are covered once every 5 years.
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 a panoramic radiographic image when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The records show that you received a panoramic radiographic image on October 19, 2017, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a panoramic radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
You asked the Plan to pre-approve 10 additional occupational therapy visits. You say that the requested 10 additional occupational therapy visits are medically necessary. The Plan denied your request. The Plan says the requested 10 additional occupational therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 10 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. Based on the available records the enrollee appears to have plateaued with therapy. She has met her prior level of functioning with toileting skills, but she appears to have plateaued with lower body dressing. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of a home exercise program with caregiver support appears appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dermatology services provided by an in-network specialist from April 29, 2021, through June 25, 2021.
You asked the Plan to waive the copayment for dermatology services. You say that the provider's office is billing for services that were not provided and you feel they are abusing both you and the insurance plan. The Plan denied your request. The Plan says upon clinical review of the medical records, it was determined that the reported services support the billing. The Plan says the assessed cost-share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for Physician/Practitioner Services, Including Doctor's Office Visits.
You have been asked to pay a total of $85 in copayments for dermatology services. Dermatology services are a specialty service, which falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. According to the records, you have a total of 17 claims of specialist services. (17 claims  $5 = $85). 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 dermatology services provided by an in-network specialist from April 29, 2021, through June 25, 2021.
Your complaint about potentially falsely billed services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. The Plan stated these concerns were handled in separately created grievance cases. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power mobility device (PMD) (K0800).
You asked the Plan to pre-approve the PMD. You say that the enrollee requires the device. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 PMD. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found while the enrollee has a personal mobility deficit that would impact their MRADLs, there is no evidence that the enrollee would not be helped sufficiently with a cane, walker, or wheelchair. There was no documentation that the powered scooter could be used 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 the PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power mobility device (PMD) (K0800).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-one.
You asked the Plan to pre-approve Synvisc-one. You say that the services are 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 Synvisc-one. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-one.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nayzilam.
You asked the Plan to pre-approve Nayzilam. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nayzilam.
Benefits for Nayzilam may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 83036, 80053, and 85025
provided on April 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services coded 83036, 80053, and 85025 provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021 by a non-participating provider.
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 services were rendered by a non-participating provider without prior authorization.
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 referring provider 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 on June 14, 2021 by a non-participating provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services provided on April 5, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. Specifically, the provided records document a referral from the enrollee's attending or primary care physician. The Plan has not offered any other rationale for denial. Therefore, we decided that the Plan has to pay for psychotherapy services provided on April 5, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on May 24, 2021.
You asked the Plan to pay for the ambulance transport and mileage. You say that these services were medically necessary because the enrollee could not have traveled by any other means without endangering their health. The Plan denied your request. The Plan says the criteria for coverage is not met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 the ambulance transport and mileage. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that the enrollee was being transported back to an assisted living facility after emergency room evaluation for a fall. Our reviewer also found that the record does not indicate that the enrollee's clinical condition is such that other methods of transport were contraindicated. 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 ambulance transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power scooter (K0812).
You asked the Plan to pay for a power scooter. You say that your scooter is not working. The Plan denied your request. The Plan says you previously received a scooter in 2018.
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment, which cannot be less than 5 years. We looked at the file and Medicare rules. The record shows that you previously received a power wheelchair in 2018. The submitted records do not document the loss of or irreparable damage to your current wheelchair. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pay for a power scooter (K0812).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the notes do not show that you have complex care needs that require a coordinated team approach. The Plan states notes do not show that your must have an intensive therapy program (three (3) hours a day, at least five (5) days a week) in order to improve self-care functioning. The Plan states your medical and therapy needs could be met in a skilled nursing unit.
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
weakness, anemia, gastrointestinal bleeding, and atrial fibrillation 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 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 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from February 19, 2021, to May 1, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you never had to pay for nursing home services before and you cannot afford this. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for days 1-20, and a $184 copayment per day for days 12-100 for skilled nursing facility services. Records show that you were in the SNF from February 19, 2021, to May 1, 2021, for a total of 71 days. You
were charged $0 for the first 20 days in accordance with your contract. For the remaining 51 days, you were charged a $184 copayment per day for a total of $9384. However, you only had $6043.04 remaining on your out-of-pocket maximum for the year, so that is the amount you are being charged. 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 skilled nursing facility (SNF) services you received from February 19, 2021, to May 1, 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 SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 76-year-old male with a cerebrovascular accident. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. IN conclusion, you do 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 SNF care 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional physical therapy sessions of the 30 originally requested.
You asked the Plan to pre-approve 15 physical therapy sessions. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 15 physical therapy sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found that the request for the additional remaining 15 of the 30 requested therapy sessions is not generally accepted as specific and effective therapy for your condition beyond what was approved by the Plan. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or by or under the supervision of a therapist beyond the approved amount without evidence of ongoing skilled need from the already approved therapy. The requested services are not part of a maintenance program, nor are the specialized skill, knowledge, and judgment of a qualified therapist required to establish, design, and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 physical therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 additional physical therapy sessions of the 30 originally requested.