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

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and local anesthesia
(D9210) provided on April 20, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodontal maintenance and local anesthesia. You say that you were told by
the Plan's customer service at the beginning of June 2021 that this dental claim was being processed and you
could expect to receive payment in 4 to 6 weeks. The Plan denied your request. The Plan says the treating
provider opted out of Medicare effective March 2, 2013, to March 2, 2023. The Plan also says that you made
no calls to the Plan prior to these services being rendered.

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
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodontal maintenance (D4910) and local anesthesia (D9210) provided on
April 20, 2021 by a Medicare opt out provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) service.
You asked the Plan to pre-approve SNF services. You say that you need to stay in the faculty as there is no one at home to take care of you as you cannot be by yourself. The Plan denied your request. The Plan says that you no longer require daily skilled nursing or skilled rehabilitation services.
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 your condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) service.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient eye surgery you had on March 4, 2021.
You asked the Plan to waive the cost sharing for the outpatient eye surgery. You say that you cannot afford this bill. The Plan denied your request. The Plan says you had not met your deductible at the time of these services. The Plan says that the deductible and copayment were charged 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 have a $1000 annual deductible that applies to outpatient surgery. After the deductible is met, you must pay a $395 copayment for outpatient surgery.
You have been asked to pay your $1000 deductible and a $395 copayment for the outpatient eye surgery. 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 cost sharing for the outpatient eye surgery you had on March 4, 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 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 she 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 sepsis and acute kidney injury. 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 pay for refraction provided on June 8, 2021.
You asked the Plan to pay for determination of refractive state (92015). You say that this service is a covered benefit. The Plan denied your request. The Plan says refraction is not covered by Medicare or the Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover refraction. We looked at the file and the Plan's rules. Neither Medicare nor the Plan cover refraction. Based on this information, we decided that the Plan's rules for coverage of determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for refraction provided on June 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on March 30, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee was seen thrice on the same date of service. The Plan denied your request. The Plan says the code was not billed with a modifier to allow for separate payment. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 99284 was billed with code 99285. Code 99284 may be eligible for payment when billed with this code pair. However, the claim provided does not show that the code at issue was 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 emergency room services provided on March 30, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zirabev.
You asked the Plan to pre-approve Zirabev. You say that the enrollee has kidney disease and cannot have a platinum drug. The Plan denied your request. The Plan says that the requested drug is not recommended for platinum sensitive patients with ovarian cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Zirabev. Our physician reviewer found that the enrollee has ovarian cancer. She is status post Carboplatin and Taxol, and Carboplatin and Doxil, with progression. She cannot tolerate a platinum-based agent. The requested use of Zirabev is supported by the National Comprehensive Cancer Network (NCCN) compendia due to her platinum drug intolerance. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Zirabev have been met. Therefore, we decided that the Plan has to pre-approve Zirabev.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), cone
beam computed tomography (CT) capture and interpretation (D0364), and first intraoral periapical x-ray
(D0220) provided on June 30, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, cone beam CT capture and
interpretation, and first intraoral periapical x-ray. You say that in your opinion, you do not believe that a CT
scan was necessary. You also say that you were not advised that you were getting a CT scan and believed it
was a regular x-ray. The Plan denied your request. The Plan says the problem focused limited oral evaluation
and cone beam CT capture and interpretation are not covered services. The Plan also says that your benefits for
the first intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded.
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 problem focused limited oral
evaluation (D0140) and cone beam CT capture and interpretation (D0364) are not among those covered under
this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The
record shows that you received a first intraoral periapical x-ray (D0220) on June 3, 2021 and your intraoral xrays
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation (D0140), cone beam CT capture and interpretation (D0364), and first intraoral
periapical x-ray (D0220) provided on June 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on February 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician in the medical record.
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. The submitted claim does not include a referring provider for the 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 individual psychotherapy services (90832) provided on February 26, 2021 by 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 oral evaluation (D0150), topical
application of fluoride varnish (D1206), full mouth debridement (D4355), and house/extended care facility call
(D9410) provided on June 11, 2021, by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, topical application of fluoride varnish, full
mouth debridement, and house/extended care facility call. You say that the enrollee has had two dental visits
from this provider, who was chosen because he would come to the enrollee's home to perform the dental work.
You also say that you feel that using this provider was the safest way to care for the enrollee's dental needs.
The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The
Plan also says that the enrollee's plan does not offer coverage for services rendered by non-participating
providers.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150), topical application of fluoride varnish (D1206), full mouth
debridement (D4355), and house/extended care facility call (D9410) provided on June 11, 2021, by an OON
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator (E0747).
You asked the Plan to pre-approve osteogenesis stimulator. You say that the enrollee is a high risk for a nonunion
and wants to avoid a costly surgery. The Plan denied your request. The Plan says the request is not
medically necessary as the records do not support that the criteria has been met.
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 osteogenesis stimulator. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found in this case, there is radiographic evaluation of the right knee that revealed a healing
right femur fracture with intact hardware post ORIF on 7/28/21. There was no documentation of nonunion,
failed fusion, or pseudoarthrosis that would necessitate the requested osteogenesis stimulator. There is no
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this
request as an exception to the guidelines. Therefore, the requested osteogenesis stimulator is not medically
necessary
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve osteogenesis stimulator (E0747).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (K0606), provided on February 28, 2021, and March 31, 2021.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that the service should be covered. The Plan denied your request. The Plan says the 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the automatic external defibrillator. This item falls within the durable medical equipment (DME) and related supplies 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 coinsurance for the automatic external defibrillator (K0606), provided on February 28, 2021, and March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and
first intraoral periapical x-ray (D0220) provided on June 14, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray.
You say that you went to your dental specialist due to a severe pain in your tooth because you could not wait
any longer. You also say that your dental coverage includes deep cleaning, panoramic x-rays, diagnosis x-rays
(which is the particular service you received), crowns, and more. The Plan denied your request. The Plan says
these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service
to verify benefits and provider eligibility. 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
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on June
14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 10, 2019 to July 8, 2019.
You asked the Plan to pay for SNF services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, the claim was billed with RVB for 14 days and RVC20 for 15 days. 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 SNF services. Our reviewer says that the documentation does not support the Resource Utilization Group (RUG) score billed. Our physician reviewer found the documentation did not include a change of therapy (COT) other Medicare required assessment (OMRA) to support billing after June 30, 2019. Therefore, the services cannot be paid as billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 10, 2019 to July 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance response and treatment without
transport (A0998) provided on August 11, 2020.
You asked the Plan to pay for the ambulance treatment without transport. You say that these services were
medically necessary, and you feel they should be covered. The Plan denied your request. The Plan says the
ambulance benefit is a transportation benefit. Without transportation, there is no payable service
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 11, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the emergency ambulance response and treatment
without transport (A0998) provided on August 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on March 3, 2021.

You asked the Plan to pay for physical therapy. You say that The Plan denied your request. The Plan says
physical therapy is 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 pay for physical therapy. Our reviewer says that
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the March 3, 2021, therapy visit was not generally accepted as
specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy and the records
do not demonstrate that the unique skills of a professional therapist were required to safely and effectively
provide treatment, that the services could have been safely and effectively performed only by a therapist, or by
or under the supervision of a therapist. The enrollee has already been instructed in a home exercise program.
The requested service was not part of a maintenance program, are the specialized skill, knowledge and
judgment of a qualified therapist was not required to establish, design and/or deliver a program to maintain the
enrollee 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 physical therapy have not been met. Therefore, we decided that the Plan does
not have to pay for physical therapy provided on March 3, 2021.