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

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 30, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because you pay your premiums and the Plan does little to help with costs. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $225 copayment for advanced imaging services. You have been asked to pay the allowed amount of $145.17, which is less than the $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the neck (70549, 70544).
You asked the Plan to pre-approve the MRA. You say that the MRA is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRA. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the enrollee has had prior carotid doppler study. MRI/MRA of the neck will not provide any new information that will benefit the management of the enrollee's condition. 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 MRA have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the neck (70549, 70544).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation.
You asked the Plan to pre-approve the dental consultation. You say that you are currently on a liquid diet due to your teeth, and this is creating stomach problems for you. The Plan denied your request. The Plan says this is not a covered procedure.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve 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. Therefore, we decided that the Plan does not have to pre-approve a dental consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system.
You asked the Plan to pre-approve a combination sit to stand frame/table system. You say that you cannot
stand up without the assistance of the sit to stand device. The Plan denied your request. The Plan says this
device is specifically non-covered per Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. A combination sit to stand frame/table system is statutorily not
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a combination
sit to stand frame/table system have not been met. Therefore, we decided that the Plan does not have to preapprove
a combination sit to stand frame/table system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network inpatient rehabilitation facility (IRF).
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 services are available from network providers.
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 a referral to an out-of-network inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need the power
seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature 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 feature is not
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation
feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extraction of residual tooth roots, tooth 10 (D7250) gingival irrigation tooth 9 (D4921) and unspecified oral surgery procedure, tooth 9 (D7999).
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial of the dental services. The first denial says benefit exhausted and this is your first visit for the year. The other denial says provider not in network and this is the same office and dentist you saw the time before. The Plan denied your request. The Plan says the benefit for extractions has been exhausted. Gingival irrigation and unspecified oral surgery procedure are not covered under the 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. The plan allows 1 extraction per calendar year. The records show that an approval was issued for a surgical extraction coded as D7210 on March 1, 2020. 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 surgical extraction of residual tooth roots, tooth 10 (D7250) gingival irrigation tooth 9 (D4921) and unspecified oral surgery procedure, tooth 9 (D7999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that you do not agree with the Plan's denial and
want to appeal. The Plan denied your request. The Plan says this service is 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 pre-approve a
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on August 28, 2019. 
 
You asked the Plan to pay for the maxillary partial denture and mandibular partial denture. You say that you are requesting a full refund from the initial provider because you were charged for poor and incomplete services. You also say that you are on a fixed income. The Plan denied your request. The Plan says these services were paid correctly. 
 
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 contract clearly states that you are responsible for a 70% coinsurance for partial dentures when they are received by an in-network provider. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on August 28, 2019.  
 
Your complaint about your dissatisfaction with the treating provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on January 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 71101. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71101. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete lower denture (D5120).
You asked the Plan to pre-approve the dental services. You say that your current partial is breaking the teeth you have left. You don't understand what you're supposed to do when your bottom teeth are infected as a result of a faulty partial that you can't replace. The Plan denied your request. The Plan says the benefit has been exhausted.
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 health plan contract says that dentures are covered one per arch every 5 years. The records show that a lower denture was received on August 26, 2016. This benefit will not be available until August 26, 2021. 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 complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transcutaneous Electrical Nerve Stimulators (TENS)
device (E0730).
You asked the Plan to pre-approve TENS device. You say that the records provided should support the
necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee does not meet the
medically necessary criteria.
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 TENS device. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in the case of this enrollee, the provided records suggest that TENS was prescribed to treat
chronic low back pain, not postoperative pain. There was no evidence of the enrollee having been enrolled in a
clinical trial. There were no other extenuating circumstances which might meet criteria for this device.
Therefore, this request for TENS does not meet the requirements listed in the LCD/PIM for Medicare coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TENS device have not been met. Therefore, we decided that the Plan does not
have to pre-approve Transcutaneous Electrical Nerve Stimulators (TENS) device (E0730).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the face-down positioning device.
You asked the Plan to pre-approve the face-down positioning device. You say that the enrollee needs the Face-Down Recovery System after surgery. The Plan denied your request. The Plan says a Face Down Positioning Device 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. Medicare will not pay for precautionary equipment. Therefore, we decided that the Plan does not have to pre-approve the face-down positioning device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure Max Protein (B4150) and Lactaid Fast Acting 9000 Unit Tablet.
You asked the Plan to pre-approve the Ensure and Lactaid supplements. You say that you feel that these should be covered due to your medical condition and request reconsideration. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 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. The items you asked the Plan to pre-approve are nutritional supplements and self-administered drugs. Therefore, we decided that the Plan does not have to pre-approve Ensure Max Protein (B4150) and Lactaid Fast Acting 9000 Unit Tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G myoelectric orthotic device (L8702).
You asked the Plan to pre-approve the orthosis. You say that the enrollee continues to remain with an extremely weak left upper extremity. You are committed to seeing this reasonable and medically necessary care approved. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro 2 Motion G myoelectric orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit for dentures to be provided by
an out-of-network prosthodontist.
You asked the Plan to pre-approve the outpatient office visit. You say that you need a consult with a
prosthodontist due to your loose and missing teeth. You also say that you cannot chew, and you are in pain.
The Plan denied your request. The Plan says this service is not covered by your plan. The Plan also says that
this 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.
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 the
outpatient office visit for dentures to be provided by an out-of-network prosthodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has difficulty checking blood sugar due to neuropathy. The Plan denied your request. The Plan says a CGM is not covered by Medicare when an enrollee is not on insulin. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at review the file and Medicare rules. The enrollee is not insulin treated so the Medicare coverage criteria for a CGM is not met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gauze provided on March 25, 2020.
You asked the Plan to waive the coinsurance for the gauze. You say that you didn't receive any items listed on your explanation of benefits. You say that you don't need and haven't used any gauze. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for medical supplies. You have been asked to pay $44.76, which is 20% of the allowed amount for the gauze. The allowed amount is $223.80 (20% x $223.80 = $44.76). The gauze falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 gauze provided on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0274, D0120, D1110) provided March 4, 2020.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the services provided out-of-network 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 dental services (D0274, D0120, D1110) provided March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bed alarm (K0108).
You asked the Plan to pre-approve the bed alarm. You say that the alarm is medically necessary for the
enrollee's safety. The Plan denied your request. The Plan says the item 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 bed alarm (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture (D5213).
You asked the Plan to pre-approve the dentures. You say that the records provides should support the necessity
of the services. The Plan denied your request. The Plan says this service is not covered under the 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, 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 the
upper partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee has difficulty with correct positioning and needs a new power wheelchair. The Plan denied your request. The Plan says the power seat elevation feature is a convenience function.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature 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 power wheelchair power seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve the molded foot inserts (L3020). You say that the enrollee needs the inserts. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that replacement has been diagnosed for tooth #19 due to porcelain breakage on the initial crown. The Plan denied your request. The Plan says this service is 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 pre-approve a core buildup, including any pins when required (D2950).