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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you had a hospital stay for laryngeal cancer and were discharged home with wound care and tube feedings. You are tolerating a soft diet. The records show that you do not need skilled nursing or skilled therapy services. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG and chest x-ray provided on November 25, 2019.
You asked the Plan to waive the copayment for the EKG and chest x-ray. You say that you were told the Plan would cover the checkup. You say that this should be paid in full. The Plan denied your request. The Plan says the copayment 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 $15 copayment for each Medicare covered diagnostic procedure and test at an in-network PCP office. You have been asked to pay a $15 copayment for the EKG and chest x-ray. The EKG and chest x-ray fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the EKG and chest x-ray provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the filling (D2394) provided on October 23, 2019.
You asked the Plan to waive the copayment the dental service. You say that you were not aware there was a copayment for dental services. The Plan denied your request. The Plan says there is a $50 copayment for comprehensive dental services.
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 Plan asked you to pay $50, which is less than 50% of the allowed amount for the services. Therefore, we decided that the Plan does not have to waive the copayment for the filling (D2394) provided on October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that PET scans are only covered for certain indications. 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 PET scan. Our reviewer says that the documentation does not support that the requested PET scan is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of a mild cognitive impairment. The enrollee has multiple factors that may be contributing to her cognitive complaints, including but not limited to sleep disorders, psychiatric conditions/mood disorders and other chronic health conditions. The general utility of a PET/CT scan in the evaluation of cognitive impairments is to differentiate between fronto-temporal dementia and Alzheimer's Dementia, when an enrollee presents with an overlapping clinical appearance. Both FTD and AD are commonly and customarily diagnosed on the basis of clinical evaluation/findings. A PET/CT scan alone cannot establish a diagnosis of AD or FTD. Nor can a PET/CT scan (of the brain) be used to rule in a diagnosis of another form of dementia/cognitive impairment (e.g. those due to vascular changes, mood disorders, etc). The enrollee does not meet criteria for the requested 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 a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (V2203) provided on November 20, 2019.
You asked the Plan to pay for the items. You say that the providers office contacted the Plan and were told about the $100 benefit. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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. Your EOC states that you receive a total credit of $100 toward purchase of lenses/frames and contact lenses. After Plan paid benefits for eyeglasses (lenses and frames) or contact lenses, you are responsible. The Plan paid $100 for service code V2020 (frames purchases). The provider billed a total of $296 for items received on date of service November 20, 2019, and the plan paid the maximum amount of $100. Hence, you are responsible for
the remaining cost of the vision items in the amount of $196. Therefore, we decided that the Plan does not have to pay for spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (V2203) provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS device and leads for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is in a lot of lower back pain. The Plan denied your request. The Plan says that the medical records submitted did not show the patient was in a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered when the above criteria are met. We looked at the file and Medicare rules. The file does not indicate the enrollee is participating in a clinical study. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a TENS device and leads for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominoplasty (15847) and a reduction mammoplasty (19318).
You asked the Plan to pre-approve an abdominoplasty and a reduction mammoplasty. You say that you have a persistent rash and irritation at the inguinal area. The Plan denied your request. The Plan says the requested services do not serve a medical purpose and are cosmetic in nature.
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 an abdominoplasty and a reduction mammoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not diagnosed with macromastia and any functional impairment associated with breast ptosis has not been documented. Therefore, reduction mammoplasty does not satisfy Medicare medically necessary criteria for this enrollee. As failure of typical
dermatologic management of chronic rashes related to the overlapping abdominal pannus has not been documented, it is not clear if panniculectomy/abdominoplasty would exceed the enrollee's medical need. Therefore, abdominoplasty does not satisfy Medicare medically necessary criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an abdominoplasty and a reduction mammoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominoplasty (15847) and a reduction mammoplasty (19318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for hearing services provided on November 6, 2019 by an out-of-network provider.
You asked the Plan to waive the deductible for the hearing services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan applied $17.07 towards your annual deductible amount of $750. You were concerned that you were being charged for a hearing test, but actually this amount is applying towards your deductible because the provider was out-of-network. 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 deductible for hearing services provided on November 6, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig for the enrollee.
You asked the Plan to pre-approve the wig. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 wig for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after April 4, 2020.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs. The enrollee was treated for intermittent pain. The enrollee required total assistance for functional mobility. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 continued SNF coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after April 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you never see the patient. You say that these services were an extension of an in-office visit. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 has network providers available who can provide 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 lab work provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ajovy 225 mg/1.5ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is a drug that you give yourself.
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 Ajovy 225 mg/1.5ml syringe for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
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 the items are not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. The Plan has approved a Group 3 PWC for the enrollee. The approved PWC has power options that come with their own switches; therefore, the requested electronic connection is not needed. The expandable controller and harness are not needed because the file shows that the enrollee has adequate upper limb strength to control the power options using the approved equipment. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair itself and the other requested items/accessories, for the enrollee.
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The member has requested a Group 3 power wheelchair to use for community outings. The member is able to ambulate at least 10 steps in the house and has an aide to help at home. The member is able to independently weight shift, does not use a catheter to urinate and has no pressure ulcers. Medicare does not cover a power wheelchair for community access only. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair itself and the other requested items/accessories, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care services provided on July 3, 2019.
You asked the Plan to waive the copayment for vision care services. You say that this was a routine exam. The Plan denied your request. The Plan says the services were not routine.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a medical eye examination on July 3, 2019. The services were not routine; therefore, you are asked to pay a $35 copayment for the vision care services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for vision care services provided on July 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica for the enrollee.
You asked the Plan to pre-approve Lyrica. You say that the enrollee has tried other drugs which were not effective. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Lyrica for the enrollee.
Benefits for Lyrica 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 periodic oral evaluations and prophylaxes provided by an out-of-network provider on May 20, 2019 and November 12, 2019.
You asked the Plan to pay for the periodic oral evaluations and prophylaxes. You say that you paid the entire bill for these services. You also say that you are not required to waive liability for your claim. The Plan denied your request. The Plan says they confirmed that this provider is a non-participating provider with your plan. The Plan also says that services need to be provided in-network to be eligible for payment.
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 an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluations and prophylaxes provided by an out-of-network provider on May 20, 2019 and November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for graft, bone; nasal, maxillary or malar areas (includes obtaining graft) (CPT Code 21210) provided on April 22, 2019.
You asked the Plan to pay for the dental services. You say that you feel this is medically necessary and should be covered under your medical plan because your dental provider would not cover it. The Plan denied your request. The Plan says Dental Restoration services are not a covered benefit according to the Medicare coverage guidelines.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The service is not a covered benefit under the plan. Therefore, we decided that the Plan does not have to pay for graft, bone; nasal, maxillary or malar areas (includes obtaining graft) (CPT Code 21210) provided on April 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for single eyeglass lens (V2103) purchased on July 23, 2019.
You asked the Plan to pay for the lens. You say that you did not request this and you did not receive any single lens. The Plan denied your request. The Plan says you exhausted your benefit allowance.
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. Since your eyewear purchase costs more than $100 allowance, you pay the difference. Therefore, we decided that the Plan does not have to pay for single eyeglass lens (V2103) purchased on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the eye exams provided from July 15, 2019 to September 11, 2019.
You asked the Plan to waive the coinsurance for eye exams. You say that you disagree with the amount you were reimbursed. You say you paid $300 for the visits and were only returned $240. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 20% coinsurance for out-of-network covered services. You have been asked to pay a total of $60 which is 20% of the total allowed amounts for the eye exams. The total allowed amount is $300. ($300 x 20% = $60). The record shows you were reimbursed $240. ($300 - $60 = $240).
The eye exams fall within the "Vision care" 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 eye exams provided from July 15, 2019 to September 11, 2019.