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

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020.
You asked the Plan to pay for the laboratory services. 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.
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 test 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 provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extractions (D7210) for teeth # 21, 22, 23, 24, 25, 26, 27 and 28.
You asked the Plan to pre-approve the dental services. You say that the enrollee was notified that anesthesia would not be covered under their plan. You say that the enrollee cannot afford to pay for this out of pocket. You say that the enrollee has not had dental work done in 20 years due to a traumatic experience as a child. You also say that the service is medically necessary. The Plan denied your request. The Plan says extractions are covered only for the preparation of the jaw for radiation treatments of neoplastic disease. The Plan says that the surgical extractions are not to prepare the jaw for radiation and therefore are not covered.
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 dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the requested surgical extractions are not medically necessary. Our physician reviewer found a surgical extraction involves the extraction of an erupted tooth requiring removal of bone and/or sectioning of the tooth and including elevation of a mucoperiosteal flap if indicated. The documentation does not support the need for this type of extraction procedure. Therefore, the reviewer found that the documentation provided does not support the need for the surgical extractions of teeth # 21 to 28. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, a lesser type of extraction can be performed. Additionally, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) for teeth # 21, 22, 23, 24, 25, 26, 27 and 28.
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.
You asked the Plan to pre-approve IRF care. 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.
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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging in June 2021 has demonstrated multi-level disease including mild to moderate spinal stenosis at L2-L3, the level requested for treatment, as well post fusion changes at L4-S1. The enrollee has subsequently had a fall which has exacerbated pain. Pain is not relieved by flexion. The record does not document that the enrollee is not indicated for operative intervention at more than two levels.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. 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.

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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care and private duty nursing aides or in a long-term care facility on a part time basis appear appropriate in this case. 

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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for abdominal ultrasound (76705) provided on April 26, 2021.
You asked the Plan to waive the coinsurance for the abdominal ultrasound. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an abdominal ultrasound on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an abdominal ultrasound on April 26, 2021. You have been asked to pay a 20% coinsurance for the abdominal ultrasound, totaling $20.29. The abdominal ultrasound falls within the Outpatient diagnostic tests 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 abdominal ultrasound (76705) provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided from January 27, 2020, to May 4, 2020.
You asked the Plan to pay for the mental health services. You say that the services were paid for by the plan. You say that the Plan requested a refund of the payment. You also say that the services should be covered. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided from January 27, 2020, to May 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening digital tomography of both breasts and the mammogram provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the tomography and the mammogram. You say that you were told the services would be covered because they were routine. You say you were not informed you would need approval. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the screening digital tomography of both breasts and the mammogram provided on February 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on May 6, 2021.

You asked the Plan to pay for these services. You say that the doctor recommended the vaccine. The Plan denied your request. The Plan says the services are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on May 6, 2021.

Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions provided on February 4, 2021.
You asked the Plan to pay for the extractions. You say that your teeth are brittle and continually suffer cracks
and breaks at the gum level. You say that you are under great financial burden and the services should be
covered. The Plan denied your request. The Plan says extractions 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 pay for the
extractions provided on February 4, 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 the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently
ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to
prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be
provided at a lower level of 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 13, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on January 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint blocks (64635 and 64636).
You asked the Plan to pre-approve facet joint blocks (64635 and 64636). You say that the requested facet joint blocks are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested facet joint blocks (64635 and 64636).
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve facet joint blocks (64635 and 64636). Our reviewer says that the enrollee meets criteria for the requested facet joint blocks (64635 and 64636). Our physician reviewer found the enrollee has chronic low back pain. He has tried Chiropractic and Physical therapy. He has had 2 prior Epidural Steroid Injections. He had bilateral intra-articular lumbar facet injections (4/16/21 and 5/26/21). The request is for RFA of the lumbar facet joints. The enrollee had 2 prior Intra-articular facet injections with good effect. The request is medically reasonable and 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 facet joint blocks (64635 and 64636) have been met. Therefore, we decided that the Plan has to pre-approve facet joint blocks (64635 and 64636).
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 pre-approve the hearing aid check (92593), electroacoustic evaluation hearing aid (92594, 92595), hearing aid fitting (V5011), hearing aid accessories (V5267), conformity evaluation (V5020) and hearing aid repair (V5014).

You asked the Plan to pre-approve hearing aid services. You say that the services are medically necessary. The Plan denied your request. The Plan says only one hearing aid test is covered a year.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only one routine hearing exam and hearing aid fitting/evaluation a year. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aid services have not been met. Specifically, one hearing aid check is covered a year and medical necessity cannot be determined for replacement hearing aids or supplies prior to test results. Therefore, we decided that the Plan does not have to pre-approve the hearing aid check (92593), electroacoustic evaluation hearing aid (92594, 92595), hearing aid fitting (V5011), hearing aid accessories (V5267), conformity evaluation (V5020) and hearing aid repair (V5014).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 16, 2020.
You asked the Plan to pay for the laboratory services. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 laboratory services provided on December 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on April 21, 2021.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the ambulance services. 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 ambulance services provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scaling and root planing (D4342) provided May 7, 2021.

You asked the Plan to pay for the scaling and root planing. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is not covered under your plan.

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 scaling and root planing (D4342) provided May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.