Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that walking sometimes exerts you and you need oxygen. The Plan denied your request. The Plan says that an additional portable oxygen concentrator would be considered a duplication of services.
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 file shows that you have a portable oxygen system and a stationary oxygen concentrator. A portable oxygen system and a stationary oxygen concentrator serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula, nutritionally complete with intact nutrients (B4150).
You asked the Plan to pre-approve enteral formula. You say that you are severely underweight and need the liquid drinks to assist with weight gain. You've been in this condition for a long period of time and need to start the drinks as soon as possible. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria as you are able to eat and drink with your mouth and do not have a permanent feeding tube.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve enteral formula, nutritionally complete with intact nutrients (B4150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and root canal (D3320) provided on January 15, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation and endodontic therapy. You say that you did not get a pre-estimate for these services and had no idea of the inflated charges. You also say that the procedures were unnecessary and done on the wrong day. The Plan denied your request. The Plan says cone beam CT capture and interpretation is not a covered benefit. The Plan also says that the cost share of the endodontic therapy was applied correctly per your plan 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, cone beam CT capture and interpretation is not among those covered under this benefit. The Plan contract also clearly states that you are responsible for a 50% coinsurance for root canals. The record shows that you were given a treatment plan, informing you of the estimated charges, that you signed. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and root canal (D3320) provided on January 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you have received excellent care from this provider during your initial surgery and post-surgery care and would like to receive care from them again. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
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 you need help with showering. The Plan denied your request. The Plan says this item is not a covered benefit.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over-the-bed table.
You asked the Plan to pre-approve an over-the-bed table. You say that the enrollee needs an over-the-bed table for therapy. The Plan denied your request. The Plan says an over-the-bed table is a convenience item not covered by Medicare or the Plan.
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 an over-the-bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise equipment.
You asked the Plan to pre-approve exercise equipment. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.
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 exercise equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hoyer lift with weight scale.
You asked the Plan to pre-approve a Hoyer lift with weight scale. You say that the enrollee must be weighed and a Hoyer lift with weight scale is the only way. The Plan denied your request. The Plan says a Hoyer lift with weight scale is not primarily medical in nature but a patient lift was approved on March 4, 2020.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The weight scale 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 Hoyer lift with weight scale.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased on September 27, 2019 from a nonnetwork
provider.
You asked the Plan to pay for the eyeglasses. You say that you have used the Provider for your eyeglasses many
times and have always received the $150 payment for the glasses. You state there has never been a problem in
the past and you live out of the area and have always used local providers. You state you had no way of
knowing that the status of the Provider had changed. The Plan denied your request. The Plan says you did not
purchase your eyewear from a plan optical network facility.
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. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Review of the file show that you purchased on September 27,
2019 from a non-network provider. The provider is not in-network and your EOC clearly states, the Plan will
provide a $150 allowance once every 24 months for you to use toward the purchase price of eyewear from a
plan optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction.
Therefore, we decided that t
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 16, 2019 by out of
network provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services received are not a covered benefit.
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 the office visit provided on September 16, 2019 by
the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a participation in a clinical trial to test efficacy of
continued letermovir treatment.
You asked the Plan to pre-approve the clinical trial services. You say that the enrollee's window for being able
to participate in the trial is coming to an end and this is potentially life-saving treatment. The Plan denied your
request. The Plan says they cannot approve participation in a clinical trial as the routine costs of the
treatment would be billed to Original Medicare. The Plan has approved continued visits to the Medical Center for aftercare for the bone marrow transplant.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the clinical trial services as part of a clinical trial. The Plan does
not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not
have to pre-approve a participation in a clinical trial to test efficacy of continued letermovir treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopantogram (70355) to be provided by the
Medical Center, a non-contract provider.
You asked the Plan to pre-approve the dental x-ray. You say that the x-ray is medically necessary. The Plan
denied your request. The Plan says the requested provider is out-of-network.
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 xray
when the services are medically necessary and reasonable. Services must be obtained through network
providers.
We looked at the plan contract, the file, and Medicare rules. The Provider is not a network provider. There are in-network providers that can provide the service at issue. Based on this information, we
decided that the Plan's rules for coverage of the dental x-ray have not been met. Therefore, we decided that the
Plan does not have to pre-approve an orthopantogram (70355) to be provided by the Medical Center, a noncontract
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiology oncology consultation to be provided by an
out of network (OON) provider.
You asked the Plan to pre-approve the physician services. You say that you have prostate cancer. You say that
you were previously treated at the facility in June 2018. You also say that you would like to complete your post
radiation follow ups at the facility. The Plan denied your request. The Plan says the requested provider is not a
network provider. The Plan says that the requested services can be provided within your PCP's medical group.
The Plan also says that the requested service is not urgent.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider within your PCP's medical group. The Plan has
network providers available within your PCP's medical group who can provide the items/services at issue in
this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore,
we decided that the Plan does not have to pre-approve a radiology oncology consultation to be provided by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive exam (92014) provided
by September 23, 2019.
You asked the Plan to waive the copayment for the vision services. You say that you have never heard of this eye center and think someone pulled the wool over you. The Plan denied your request. The Plan says the plan confirmed that the enrollee was seen by a provider in their facility. The was processed correctly and the correct copayment was applied.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay $65 copayment at a specialist's office for Vision care.
You have been asked to pay $65 copayment at a specialist's office for the vision services. The vision services
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 copayment for the
comprehensive exam (92014) provided by September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injection for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) with an out-of-network provider.
You asked the Plan to pre-approve the IMRT with an out-of-network provider. You say that you need to continue care for treatment and radiation. The Plan denied your request. The Plan says IMRT is available with the in-network tertiary provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 IMRT with an out-of-network provider. Our reviewer says that the criteria for coverage with an out-of-network provider have not been met. Our physician reviewer found the enrollee is not currently receiving any active treatment and/or medical management of her condition that makes it medically necessary to continue care with the out-of-network provider, as requested. The same treatment that is being requested can be provided through the in-network provide the Plan has referred to.
The in-network provider has the qualifications and expertise necessary to meet the current Standards of Care required for treatment of the enrollee's condition. The enrollee's medical management and/or follow up care can safely be transitioned in-network at this time. 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 IMRT with an out-of-network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve an office visit. You say that you are nervous about going to see a different doctor. The Plan denied your request. The Plan says the service in question is not an emergency. The Plan says that there are in-network providers available who can perform these services.
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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from August 26, 2019 through
September 6, 2019.
You asked the Plan to pay for inpatient mental health care. You say that you had no knowledge of this and
were not informed of the maximum lifetime limit of 190 days. 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 inpatient mental health care have not been met. Inpatient
psychiatric care is covered according to Medicare guidelines and is limited to 190 days per lifetime in a
Medicare certified psychiatric hospital. The records indicate you have reached your limit. Your EOC also
clearly states, there is a 190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit
does not apply to inpatient mental health services provided in a psychiatric unit of a general hospital.
When you signed up for the Health Plan effective January 1, 2018, you had already utilized 179 of his 190 days
lifetime maximum of inpatient care in psychiatric hospitals, as verified in the MARx system. You received 11
of your 190 lifetime maximum days of inpatient care at an in-network psychiatric hospital from June 5, 2019 through June 16, 2019. You have received the 190 days lifetime maximum days in accordance with CMS guidelines. Review of the file shows that you had an inpatient mental health stay in a psychiatric hospital, a contracted psychiatric hospital, from
August 26, 2019 to September 06, 2019. The Health Plan has correctly denied payment of the inpatient mental
health stay in a psychiatric hospital based on your full utilization of the 190 days lifetime maximum. Therefore,
we decided that the Plan does not have to pay for inpatient mental health care from August 26, 2019 through
September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral.
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 provider has opted out of Medicare.
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given
by a physician or other practitioner who has opted out of Medicare.
We looked at case file and the Medicare rules. We confirmed that the physician has opted out
of Medicare. 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 referral.