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

We decided that the Plan does not have to reimburse you forthe Valplast upper denture (D5001) and the Valplast lower denture (D5002) provided on October 25, 2018.You asked the Plan to reimburse you forthe dental items. You say that payment was denied because the coding was incorrect. You say that your dentist advised the coding was correct because the work that you received does not contain any type of metal.The Plan denied your request. The Plan says the Valplast (flexible base) dentures that you received are not a covered service.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 Valplast(flexible base) dentures are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe Valplast upper denture (D5001) and the Valplast lower denture (D5002) provided on October 25, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom molded orthotics, outflare wedge, and metatarsal bar wedge rocker (L3250, L3390, L3400). You asked the Plan to pay forthe orthotics. You say that you need the custom orthotics.The Plandenied your request. The Plan says you do not have a diagnosis of diabetes and these orthotics are not part of an integral brace.The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. Inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The Plan follows these same rules. We looked at the file and Medicare rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met.Therefore, we decided that the Plan does not have to pay forcustom molded orthotics, outflare wedge, and metatarsal bar wedge rocker (L3250, L3390, L3400).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the occlusal guard (D9944) provided on August 28, 2019 by the out of network provider.
You asked the Plan to pay the in network rate for the occlusal guard. You say that you recently purchased a home that is about 23 miles or more away from all participating provider and facilities. You say that you are disabled due to several brain surgeries. You also say that you cannot afford to pay. The Plan denied your request. The Plan says the occlusal guard is not a covered service.
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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the occlusal guard (D9944) provided on August 28, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (code D1206) provided on October 15, 2019.
You asked the Plan to pay for topical application of fluoride varnish. You say that you told the dental office that you only wanted covered services to be performed but they applied the fluoride anyway. 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 pay for the topical application of fluoride varnish (code D1206) provided on October 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 31, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that that $120 is a lot of money to pay with Medicare and insurance, especially since nothing was done during your visit. 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 a $120 copayment for each emergency room visit. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 emergency room visit provided on August 31, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.You asked the Plan to pre-approve Brovana. You say that this is the best option for the enrollee.The Plan denied your request. The Plan says the enrollee has not tried Perforomist (formoterol) as required by step therapy rules.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 Brovana. Our reviewer says that the criteria for coverage of Brovana have not been met. Our physician reviewer found he documentation does not support that the enrollee has tried and failed Perforomist (formoterol), or that Perforomist 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 Brovana have not been met.Therefore, we decided that the Plan does not have to pre-approveBrovana.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient hospital stay provided from April 10, 2019 through April 11, 2019.
You asked the Plan to pay for an inpatient hospital stay. You say that the care provided was medically necessary, justified, and met inpatient criteria. The Plan denied your request. The Plan says that the enrollee's emergency medical condition stabilized by 11:31 am on April 10, 2019. Subsequent care was post stabilization care which was not approved in compliance with the health plan's authorization procedures.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 pay for an inpatient hospital stay. Our reviewer says that the services were medically necessary. Our physician reviewer found based on the documentation provided, the enrollee was transferred from a  facility to the appellant facility on April 9, 2019 with a heart attack. The enrollee underwent a cardiac catheterization with coronary intervention, which was complicated by cardiac arrhythmias. The enrollee continued to have mild arrhythmias overnight. On April 10, 2019, the plan was to make medication changes and provide ongoing monitoring. He remained where he could receive immediate treatment for an arrhythmia, be returned to the catheterization laboratory if needed and be under the care of the cardiologist who had performed the catheterization was paramount. By April 11, 2019 the enrollee had remained stable on his new medications for 24 hours and was deemed appropriate for discharge/transfer.
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 inpatient hospital stay have been met. Therefore, we decided that the Plan has to pay for an inpatient hospital stay provided from April 10, 2019 through April 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-network.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on August 1, 2019.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you do not agree with the findings. 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 $225 copayment for each Medicare-covered advanced imaging service. You have been asked to pay a $225 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging 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 the myocardial perfusion imaging provided on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the prophylaxis (D1110) provided on September 18, 2019.
You asked the Plan to pay for the dental service. You say that it is your understanding that 2 cleanings are covered per year by the Plan. The Plan denied your request. The Plan says that the annual maximum amount of $650 has been exceeded.
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 did not provide documentation to substantiate their claim that the enrollee's annual maximum of $650 for dental services has been exceeded. Therefore, we decided that the Plan has to pay for the prophylaxis (D1110) provided on September 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says the enrollee's clinical condition does not require daily skilled services as an inpatient in a SNF. The Plan says that the enrollee was treated medically and is considered stable.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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not supportthat the enrollee needs daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs. While the enrollee may benefit from continuing physical therapy and occupational therapy, the records do not support the need or current ability to participate in daily therapy. The enrollee's needs are custodial in nature.  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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forcardiac rehabilitation provided from September 17, 2019 through October 23, 2019.You asked the Plan to waive the copayments forcardiac rehabilitation. You say that you were not informed there was a copayment. You say that you thought this was included with your heart health.The Plan denied your request. The Plan says the copayments 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 copayment for each Medicare-covered visit from an in-network provider.You have been asked to pay a total of $320 for cardiac rehabilitation. ($20/visit x 16 visits = $320). Cardiac rehabilitation falls withinthe "Cardiac rehabilitation services" 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 copayments forcardiac rehabilitation provided from September 17, 2019 through October 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora n Emergency Room (ER) visit (99283) provided on September 1, 2019. You asked the Plan to waive the copayment forthe ER visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must discloseto 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran Emergency Room (ER) visit (99283) provided on September 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Lumbar Spine (72158).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. Weasked 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 MRI. Our reviewer says that coverage criteria for the MRI has not been met.Our physician reviewer found in this case, there is no documentation of the patient's steady improvement and no postoperative complications. There are no neurologic findings on physical exam. The MRI is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Lumbar Spine (72158).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
August 23, 2019.
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal attendant services (S5125).
You asked the Plan to pre-approve the personal attendant services. You say that you would like reconsideration as you have issues with balance, steps and bad days when you are unable to do tasks by yourself. The Plan denied your request. The Plan says Medicare does not cover non-skilled personal care, like help with activities of daily living (ADL) like bath, dressing, eating, getting in and out of a bed or chair, moving around, and using the bathroom.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal attendant services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal attendant services (S5125).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) and primary closure of a sinus perforation (D7261) for tooth # 2.
You asked the Plan to pre-approve the dental services. You say that you expect the tooth extraction not to be covered. You say that the medical components of the procedure, the closure of the perforation and the anesthesia, should be covered. The Plan denied your request. The Plan says the services you have requested are dental in nature. The Plan says the services you requested are not covered under your medical coverage. The Plan also says that the requested services are eligible for coverage of up to $500 under your dental coverage.
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 surgical extraction (D7210) and primary closure of a sinus perforation (D7261) for tooth # 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair power seat elevation feature, standing
feature, electronic upgrade, knee support, padded chest strap, and knee support.
You asked the Plan to pre-approve the features, accessories and electronic upgrade.. You say that the enrollee
cannot stand up and needs the power seat elevation and power stand features. The Plan denied your request.
The Plan says power seat elevation and power stand features and the accessories are not primarily medical and
are not covered. The enrollee has adequate strength to control the power options using their own switches.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Neither Medicare
nor the Plan cover power seat elevation or power stand features. The electronic upgrades cannot be covered as
it is not medically necessary to control the three approved power options through the joystick. Therefore, we
decided that the Plan does not have to pre-approve power wheelchair power seat elevation feature, standing
feature, electronic upgrade, knee support, padded chest strap, and knee support.