Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cerebral perfusion analysis (0042T) provided to the enrollee on March 7, 2021.  You asked the Plan to pay for the cerebral perfusion analysis (0042T). You say that the provided cerebral perfusion analysis was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided cerebral perfusion analysis.  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 pay for the cerebral perfusion analysis (0042T). Our reviewer says that the enrollee did not meet criteria for the provided cerebral perfusion analysis. Our physician reviewer found the record indicates that the enrollee had dizziness.  The record does not indicate that the enrollee had a unilateral large vessel occlusion (LVO) in the proximal anterior circulation and was being considered for endovascular mechanical thrombectomy (EVT).  The elements of the coverage rules are not satisfied.  The requested service cannot be 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 the cerebral perfusion analysis (0042T) have not been met. Therefore, we decided that the Plan does not have to pay for the cerebral perfusion analysis (0042T) provided to the enrollee on March 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dentures (D5130, D5899, and D5140) provided on August 16, 2021.  

You asked the Plan to pay for dental codes D5130, D5899, and D5140. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says dental codes D5130, D5899, and D5140 are not covered under the Plan's supplemental 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, dental codes D5130, D5899, and D5140 are not among those covered under this benefit. The Plan is responsible for reimbursing the amount you paid for covered dental services provided by the contracted provider. Therefore, we decided that the Plan does not have to pay for the dentures (D5130, D5899, and D5140) provided on August 16, 2021.   

The Qualified Independent Contractor read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home portable ventilator.  You asked the Plan to pre-approve the home ventilator. You say that it is felt that this device is medically needed. The Plan denied your request. The Plan says the criteria for this ventilator have not been met.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our reviewer says that the requested type of ventilator is not medically reasonable and necessary. Our physician reviewer found this patient has pulmonary fibrosis, and does not have a diagnosis for which a ventilator may be covered, such as severe COPD with hypercapnia, thoracic restrictive disease, or neuromuscular disease. The patient is symptomatically improved on high-flow oxygen. There is no documentation of nocturnal hypoventilation or hypoxemia while on oxygen.  A ventilator would not be expected to help in pulmonary fibrosis because the problem is generally one of oxygenation, not hypoventilation.   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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on August 2, 2021.  You asked the Plan to pay for code 99336. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. Therefore, we decided that the Plan does not have to pay for the Domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The enrollee has not failed treatment with a BiPAP machine with AVAPS capability.   The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected.  The elements of the coverage criteria are not satisfied.  The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the simple extraction (D7140) provided on August 24, 2021.  You asked the Plan to pay for the simple extraction. You say that the tooth was decayed and no longer healthy. You also say that an infection could have set in as well as increased the chance of long-term heart disease. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you have no Supplemental Dental Rider benefits which would allow you to have additional dental 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, 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 simple extraction (D7140) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015), provided on July 29, 2021.  You asked the Plan to pay for the eye refraction. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.  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 covers one supplemental routine eye exam (including eye refraction) per year.  We looked at the file and the Plan's rules. Eye refractions outside of the annual supplemental routine eye exams are not covered. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015), provided on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tecentriq.  You asked the Plan to pre-approve Tecentriq. 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.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Tecentriq. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you $95 for vision services provided on  February 17, 2021.  

You asked the Plan to reimburse you $95 for vision services. The Plan denied your request. The Plan says the claim processed with the correct cost share.  

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.   

We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct cost share. Therefore, we decided that the Plan does not have to reimburse you $95 for vision services provided on February 17, 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 the enrollee would benefit from a SNF admission. The Plan denied your request. The Plan says the enrollee's condition does not require daily skilled 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital after a fall which caused an ankle fracture. He has been treated conservatively with casting of the lower leg and is not to bear any weight on the lower extremity. He has been treated for delirium and pneumonia. The most recent therapy documentation indicates the member remains strict non-weight bearing status therefore physical therapy has been working on bed mobility and a home exercise program. He requires some assistance for scooting. The member is medically stable and does not have any complex daily wound care, parental medications or required care for a new or malfunctioning feeding tube.  The member has stabilized medically and is ready for discharge from the hospital.  The member does not require skilled nursing and/or skilled therapy services on a daily basis.  He is medically stable and can receive further rehab services at a lower level of care.  Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.     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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ubrogepant.  

You asked the Plan to pre-approve ubrogepant. 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 ubrogepant.   

Benefits for ubrogepant 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on August 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on August 26, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the durable medical equipment provided on July 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the durable medical equipment provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on July 25, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cerebral perfusion analysis (procedure code 0042T) provided to the enrollee on March 7, 2021.  You asked the Plan to pay for the cerebral perfusion analysis (0042T). You say that the provided cerebral perfusion analysis was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided cerebral perfusion analysis.  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 pay for the cerebral perfusion analysis (0042T). Our reviewer says that the enrollee did not meet criteria for the provided cerebral perfusion analysis. Our physician reviewer found the record indicates that the enrollee was evaluated for dizziness.  The record does not document that acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior or that the enrollee was being considered for endovascular mechanical thrombectomy (EVT). The elements of the coverage rules are not satisfied.  The requested service cannot be 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 the cerebral perfusion analysis (0042T) have not been met. Therefore, we decided that the Plan does not have to pay for the cerebral perfusion analysis (procedure code 0042T) provided to the enrollee on March 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental bone graft replacement (code D7953) you received on August 2, 2021.  You asked the Plan to pay for the dental bone graft replacement. You say that you went to the dentist to have a tooth extracted and while you were in the chair, they handed you paperwork to sign and then did the procedure.  You say that the dentist did not advise you that you would have to pay in full for the procedure.  You stated that you were never told what you were getting, and you were deceived. The Plan denied your request. The Plan says the bone replacement graft is not covered under your dental benefits, but the extraction has been covered. The Plan has also provided documentation that you signed from the dentist's office two weeks prior to the services being received that explicitly stated that the bone graft replacement would not be covered.  You signed and acknowledged receiving this document.  We have confirmed that on July 15, 2021, you signed a document where you acknowledged there would be no coverage for the bone graft replacement.  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 dental bone graft replacement (code D7953) you received on August 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) beyond December 25, 2021.  You asked the Plan to pre-approve the continued SNF care. You say that the enrollee did not receive sufficient therapy during the SNF stay. The Plan denied your request. The Plan says daily skilled services are no longer required to improve or maintain the enrollee's condition.  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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the hospital on 12/5/2021 due to a fall and altered mental status. She was treated in the hospital with antibiotics and medication adjustment and improved. She was weak and deconditioned and was transferred to a skilled nursing facility for skilled nursing and therapy services on 12/08/2021. She worked with physical and occupational therapy in the nursing facility. As of 12/23/2021 she was walking 75 feet with a wheeled walker with modified independence and was modified independent to contact guard assist for transfers and was stand-by assist to minimum assist for activities of daily living.   There is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment.  This patient does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. As a practical matter, services are not required on an inpatient basis in a SNF 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) beyond December 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pontics (D6245) and retainer crowns (D6740) provided on July 15, 2021.  You asked the Plan to pay for the pontics and retainer crowns. You say that you feel the Plan should cover at least a part of the procedure, which was necessary to restore the integrity of your mouth. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. 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 pontics (D6245) and retainer crowns (D6740) provided on July 15, 2021.