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

We decided that the Plan does not have to pay for the crown provided on June 22, 2020.
You asked the Plan to pay for the crown. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered.
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 crown provided on June 22, 2020.
Appeal type: SNF
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four factors are met: 1. The patient requires skilled nursing or skilled rehabilitation services; 2. The patient requires these services on a daily basis; 3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and 4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR Section 409.31 and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 8, Section 30. The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 16, Section 110.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on March 11, 2021.
You asked the Plan to pay for the dental services. You say that you have never been able to use your dental benefits before. You say that you had to pay $4,200 out of pocket for your front tooth. You say that the exam and x-rays should be covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-rays are not listed as covered services either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 PWC with multiple power options (K0862),
headrest (E0955), power seating system (E1007), power elevating center mount foot platform (E1012), joystick
mounting hardware (E1028), cylinder tank carrier (E2208), electronic connection between wheelchair
controller and 2 or more power seating system motors (E2311), harness for upgrade to expandable controller,
(E2313), battery (E2361), skin protection wheelchair seat cushion (E2604), and expandable controller (E2377).
You asked the Plan to pre-approve group 3 power wheelchair with multiple power options and accessories.
You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not
medically necessary.
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 group 3 power wheelchair with multiple
power options and accessories. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet
criteria for the power seat and power recline; therefore, the Group 3 PWC with multiple power options is not
covered. Because the PWC is not covered, the accessories are also not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of group 3 power wheelchair with multiple power options and accessories have not
been met. Specifically, the enrollee does not meet the criteria for a group 3 power wheelchair with multiple
power options. As the power wheelchair is not medically necessary, the accessories are also not medically
necessary. Therefore, we decided that the Plan does not have to pre-approve a group 3 PWC with multiple
power options (K0862), headrest (E0955), power seating system (E1007), power elevating center mount foot
platform (E1012), joystick mounting hardware (E1028), cylinder tank carrier (E2208), electronic connection
between wheelchair controller and 2 or more power seating system motors (E2311), harness for upgrade to
expandable controller, (E2313), battery (E2361), skin protection wheelchair seat cushion (E2604), and
expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for walking poles purchased on January 14, 2021.
You asked the Plan to reimburse you for the walking poles. You say that you had to purchase the walking poles for the walking class. The Plan denied your request. The Plan says a Wellness Allowance towards the purchase of exercise equipment was only offered from October 1, 2020, to December 31, 2020.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses up to $250 per calendar year towards memberships in instructional fitness classes not equipment. The Plan's rules for coverage of gym benefits have not been met because equipment is normally not covered, and the poles were purchased outside the temporary allowance timeframe. Therefore, we decided that the Plan does not have to reimburse you for walking poles purchased on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 3, 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 92136 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 92136 is ophthalmic biometry by partial coherence
interferometry with intraocular lens power calculation.
We find that CPT code 92136 is not supported in the medical record. Specifically, there is no documentation of an ophthalmic biometry report. 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 pay for the testing services rendered on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).
You asked the Plan to pre-approve a group 1 power operated vehicle. You say that it is medically necessary for you to receive a power operated vehicle due to the potential for falls. The Plan denied your request. The Plan says the coverage criteria for this device have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73222).
You asked the Plan to pre-approve the MRI of the shoulder. You say that the service 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 MRI of the shoulder. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found plain films did not demonstrate injury. The enrollee underwent physical therapy with resolved range of motion on examination. The enrollee was offered injection for pain but declined. The enrollee requested MRI. The medical record does not indicate how the MRI would alter management at this time given functional improvement.
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 of the shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73222).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha Sureclick. You say that this medication is essential to your health. The Plan denied your request. The Plan says this drug is not covered for your condition by your Medicare Part B.
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 Repatha Sureclick.
Benefits for Repatha Sureclick 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a
participating provider on February 17, 2021.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with
these charges. The Plan denied your request. The Plan says the correct copayment has been applied.
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 enrollee's contract with the Plan clearly says that enrollees
must pay a $395 copayment for outpatient hospital services/non-surgical.
The enrollee has been asked to pay $373.83 which is less than your copayment amount of $395 for outpatient
hospital services. The correct copayment has been applied to the services that were provided. Outpatient
hospital services fall within the outpatient hospital services/non-surgical benefit category. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for outpatient hospital services provided by a participating provider on
February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (62284) and imaging guidance (77003) provided on September 1, 2020.
You asked the Plan to pay for an injection and imaging guidance. You say that these were separate and distinct
procedures. The Plan denied your request. The Plan says these services are not separately payable without a
modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes
62284 and 77003 have a bundled relationship with code 62305 and cannot be paid as billed. These codes
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for an injection (62284) and imaging guidance
(77003) provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visits provided on October 12,
2020, and October 19, 2020.
You asked the Plan to waive the cost share for the office visits. You say that you were never told you would
have to pay a coinsurance. The Plan denied your request. The Plan says you have been asked to pay 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 $400
deductible that applies to out-of-network office visits and 30% coinsurance for provider and professional
services provided by and out-of-network PCP's office or specialist's office.
Your office visits you have been asked to pay for falls within the "Physician/Practitioner services, including
doctor's office visits" benefit category. See chart below.
Date of Service Services Allowed Amount Deductible/Coinsurance Member
Liability
October 12, 2020 Office visit $118.76 $400 $63.33 - You met
your deductible
with this amount.
$55.43 - This is
the remaining
allowed amount
after the
deductible was
applied.
30% $16.63
October 19, 2020 Office visit $118.76 30% $35.63
Total $115.59
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the cost share the office visits provided on October 12, 2020, and October 19,
2020.
Your complaint about the benefit design 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an
inpatient basis, at a SNF level of care as of July 1, 2021. Your function was at or near your prior level of
function and you could be discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be performed by an out-of-network provider.
You asked the Plan to pre-approve the medical services. You say that the enrollee has been seeing this provider since the date of the accident and has been following the enrollee through their three (3) different hospitalizations. You state the provider wanted to wait on surgery and watch the enrollee through their rehabilitation then re-evaluate the enrollee for possible surgery. The Plan denied your request. The Plan says this can be managed by an in-network provider who meets Medicare time/distance criteria, and also has an available appointment within seven (7) days.
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 consultation to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic services provided on April 5, 2021, by an outof-
network provider.
You asked the Plan to pay for the orthopedic services provided by an out-of-network provider. You say that
you injured yourself while out of the area and were not near an Urgent Care. The Plan denied your request. The
Plan says there is no compelling records that this was urgent/emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 non-emergent/urgent
services provided without authorization. Therefore, we decided that the Plan does not have to pay for the
orthopedic services provided on April 5, 2021, by an 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 - excluding varnish
(D1208) received December 3, 2020.
You asked the Plan to pay for the topical application of fluoride - excluding varnish. You say that the provider
in this case was in-network. The Plan denied your request. The Plan says although the provider is in-network,
the requested service is not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride - excluding varnish (D1208) received December 3, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a chemotherapy regimen (Pemetrexed, Carboplatin, Pembrolizumab, Ondansetron, Famotidine, Diphenhydramine, Aprepitant) for the enrollee.
You asked the Plan to pre-approve the regimen. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee has already completed initial treatment with: carboplatin, abraxane, and radiation.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 regimen. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee received palliative radiation with radiosensitizing carboplatin and paclitaxel then abraxane completed the end of May 2021. The enrollee has metastatic disease and plan is to treat with carboplatin, pemetrexed and pembrolizumab with supportive medications. The enrollee is PD-L1 negative. This is a standard regimen for metastatic non-small-cell adenocarcinoma of the lung. The service is reasonable and 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 regimen have been met. Therefore, we decided that the Plan has to pre-approve a chemotherapy regimen (Pemetrexed, Carboplatin, Pembrolizumab, Ondansetron, Famotidine, Diphenhydramine, Aprepitant) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a split night titration study.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says there are health conditions that may affect the results of a home sleep study.
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 the study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have known obstructive sleep apnea, and has been doing well on CPAP. It is not necessary to repeat a sleep study just because replacement supplies or equipment are needed. You can be continued on the current CPAP settings, or started on auto-titrating CPAP if the settings are unknown. If your current device is not functioning properly, if should be evaluated by a vendor. Compliance and AHI should be assessed within 3 months. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a split night titration study.