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

We decided that the Plan does not have to pre-approve a cone beam CT capture with interpretation (D0364) and consultation (D9310).
You asked the Plan to pre-approve the dental services. You say that you have run out of antibiotics. You say that you have developed an infection. The Plan denied your request. The Plan says cone beam CT capture with interpretation is not listed as a covered service. The Plan says that consultation is not listed as a covered service either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam CT capture with interpretation (D0364) and consultation (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 13, 29, 30 and 31.
You asked the Plan to pre-approve the crowns for teeth # 13, 29, 20, and 31. You say that the crowns are medically necessary. You say that your teeth are cracked and chipped. You say that it is hard for you to chew because of the pain. You also say that your gums are swollen, and your doctor has to provide medication for the inflammation. The Plan denied your request. The Plan says the crowns are not medically necessary.
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 crowns are not medically necessary. Our physician reviewer found the documentation provided does not indicate significant coronal breakdown due to caries or fracture. Therefore, the reviewer found that the requested crowns are not medically reasonable or necessary.
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. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 13, 29, 30 and 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this item is necessary to meet your needs. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxycodone-acetominophen.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 oxycodone-acetominophen.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve continued coverage of a CPAP device. You say that the CPAP machine continues to be medically necessary. The Plan denied your request. The Plan says the compliance criteria for CPAP coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that continued coverage of the CPAP machine is subject to the compliance criteria listed 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 continued coverage of a CPAP device. Our reviewer says that the requested coverage of the CPAP device is not medically reasonable and necessary. Our physician reviewer found you are an 86-year-old man who is using a CPAP machine. In this case, the record indicates that you have been on CPAP since July 2020. At that time, you were compliant 79% of the time within the first three months of using the machine. However, subsequent compliance records indicate compliance between 20-50% of the time. There is no documentation of improvement of symptoms. Therefore, the elements of the coverage determination are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement calf/rest pads (E0995) for a power wheelchair.
You asked the Plan to pre-approve replacement calf/rest pads (E0995). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that replacement calf/rest pads are included in a Group 3 PWC described by code K0861. Review of the file shows that the Plan approved the requested Group 3 PWC and all requested accessories except for the replacement calf/rest pads. The replacement calf/rest pads are already included in the approved Group 3 PWC and therefore do not need to be approved separately. Therefore, we decided that the Plan does not have to pre-approve replacement calf/rest pads (E0995) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special lenses after cataract surgery.
You asked the Plan to pre-approve the special lenses. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare only covers regular lenses after surgery.
The Plan must follow Medicare rules. The rules say that Medicare benefits include a conventional intraocular lens (IOL) following cataract surgery. This request for special lenses exceeds the Medicare benefit after cataract surgery. Based on this information, we decided that Medicare rules for coverage of the special lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve special lenses after cataract surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300), push handles (K0108) and base wedge (K0108).

You asked the Plan to pre-approve the power seat elevation system, push handles, and base wedge. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered benefits.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that a power seat elevation system will not be covered. The rules also say that there is no separate payment for mounting hardware for a seat or back cushion.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system, push handles, and base cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300), push handles (K0108) and base wedge (K0108).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of stroke and is living at home. She is having increasing weakness and gait difficulties and is receiving outpatient physical therapy. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for alcoholic neuropathy. Your 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you would like this ramp to make it easier to lift your scooter up and down into your home. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment and deductible observation services, physical therapy and occupational therapy provided by a participating provider on December 16, 2020, to December 18, 2020.
You asked the Plan to waive the copayment and deductible observation services, physical therapy and occupational therapy. You say that you do not agree with these charges for your mother. The Plan denied your request. The Plan says that the correct charges have been applied.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to send in the correct Evidence of Coverage needed to render a decision. Therefore, we decided that the Plan has to waive the copayment and deductible observation services, physical therapy and occupational therapy provided by a participating provider on December 16, 2020, to December 18, 2020.
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 pulp vitality tests (D0460), treatment of root canal obstruction (D3331), and consultation - diagnostic service (D9310).
You asked the Plan to pay for the pulp vitality tests, treatment of root canal obstruction, and consultation. You say that you added a Dental Platinum Rider to your plan, therefore the requested services should be covered. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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. We checked the Plan contract and verified that they do not offer coverage for procedures D0460, D3331, and D9310 under your enhanced benefit. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests (D0460), treatment of root canal obstruction (D3331), and consultation - diagnostic service (D9310).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 12, 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 January 12, 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 multiple precision attachments (D5862) provided on September 16, 2020.
You asked the Plan to pay for the precision attachments. You say that you misunderstood your benefits and cannot afford this bill. The Plan denied your request. The Plan says this service is not covered by Medicare or by 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, 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 multiple precision attachments (D5862) provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye surgery provided on November 5, 2020.
You asked the Plan to pay for the services provided. You say that the services were to correct a problem stemming from cataract surgery. The Plan denied your request. The Plan says the service is not a covered benefit.
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. Although the Plan offers benefits that exceeds Medicare coverage, the surgery services provided are not among those covered under this benefit. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the eye surgery provided on November 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on October 21, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you were not billed for this service when it was provided in the past. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient surgery/in-network.

You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $182.73. The total amount you are being asked to pay is $36.55 ($182.73 x 20% = $36.55). An outpatient surgery falls within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating provider on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483 and 80307) provided on June 17, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code but the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for drug testing services (G0483 and 80307) provided on June 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the chemotherapy drug services provided from January 27, 2020, to March 9, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that you were never informed of the cost of treatment you would be responsible for. 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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance on each date of service for the chemotherapy services provided. The services fall within the Medicare Part B prescription drugs 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 cost shares for the chemotherapy drug services provided from January 27, 2020, to March 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit and x-ray received from November 23, 2020 to January 11, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit and x-ray received from November 23, 2020 to January 11, 2021.