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

We decided that the Plan does not have to pre-approve a companion to go shopping with you to the supermarket.
You asked the Plan to pre-approve the companion to go shopping with you to the supermarket. You say that you have peripheral neuropathy, carpal tunnel and fibromyalgia, which does not allow you to carry heavy things and you have tumors on your head that cause small seizures. You say that movements to the right side cause you to fall because of being unbalanced and you are blind in your right eye. The Plan denied your request. The Plan says Medicare only covers services that are related to treat a medical condition. The requested service is not covered by Medicare or by the Plan's supplemental benefits.
The Plan contract says that the Plan must cover all services covered by Original Medicare and may offer other services in addition to those covered under Original Medicare. We looked at the file and Medicare rules. The file shows that a shopping companion is not a covered supplemental benefit offered by your Plan. Therefore, we decided that the Plan does not have to pre-approve a companion to go shopping with you to the supermarket.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 15, 2019 through February 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 15, 2019 through February 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910).
You asked the Plan to pre-approve the periodontal maintenance. You say that you would like your dental claims paid under your medical benefits due to your dental diseases. The Plan denied your request. The Plan says this procedure is not listed as covered by your plan.
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 periodontal maintenance (D4910).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Yupelri (Revefenacin).
You asked the Plan to pre-approve a tier exception for Yupelri (Revefenacin).. You say that the enrollee has tried and failed several inhalers. You also say that the enrollee cannot afford this medication at its current tier and their health can be negatively impacted if a tier exception is not approved. The Plan denied your request. The Plan says this drug is covered by Medicare Part B. The Plan also says that Medicare rules say tier exceptions are not available for drugs/devices covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare Rules. Based on this information we decided that Medicare rules for a tier exception have not been met. Specifically, the drug at issue is being covered by the Plan under Medicare Part B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Yupelri (Revefenacin).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0553, K0554).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied
your request. The Plan says coverage rules are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
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 CGM. Our reviewer says that the
CGM is not medically necessary. Our physician reviewer found the enrollee uses a standard glucometer. The
records do not show that the enrollee uses insulin or medication which would cause low blood sugar.
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 CGM have not been met. Therefore, we decided that the Plan does not have
to pre-approve a continuous glucose monitor (CGM) (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD).
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 not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers PILD for beneficiaries enrolled in an approved clinical study. We looked at the file and Medicare rules. The file shows that the enrollee is not in an approved clinical study for the PILD. 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 percutaneous image-guided lumbar decompression (PILD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dexcom g6 continuous glucose monitor and supplies.
You asked the Plan to pre-approve dexcom g6 continuous glucose monitor and supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Review of the file does not support that you meet the six criteria put forth in the LCD listed above. Based on this information, we decided that Medicare rules for coverage of dexcom g6 continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve dexcom g6 continuous glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the item provided is not a covered benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you have degenerative arthritis in the ankle and the compression wrap will take the edema down and you would be able to walk. Without the wrap you're going to need a walker. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are participating providers available.
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 provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve the Vertiflex device for the enrollee.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental and investigational.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam, crowns, and core buildups rendered on
November 26, 2019 to December 19, 2019.
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 the services are 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
limited oral exam, crowns, and core buildups rendered on November 26, 2019 to December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services, each additional 30 minutes (99292) provided on September 7, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the billed services are 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 99292 is critical care services, each additional 30 minutes. We find that CPT code 99292 is not supported in the medical record. Specifically, CPT code 99292 is a time based code. In order to bill CPT code 99292, the documentation must clearly indicate that 30 additional minutes was spent providing services to the enrollee. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services, each additional 30 minutes (99292) provided on September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on September 17, 2019.
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 the claim is not payable as billed.
The Plan must follow Medicare rules. The rules say that Medicare will pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99233 with modifier -77 to indicate a repeated procedure or service. Evaluation and management services are paid only once per day; therefore, the -77 modifier is not valid. 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 subsequent hospital care rendered on September 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one additional routine eyewear.
You asked the Plan to pre-approve the additional eyewear. You say that these glasses should be covered every year instead of every two years. The Plan denied your request. The Plan says the benefit only allows for one routine eyewear.
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. The Plan covers routine eyewear once every two years. We looked at the file and the Plan's rules. Two pairs of eyeglasses (one regular and one sunglasses) were received on September 9, 2019. You are not eligible to receive this service again until September 9, 2021. Based on this information, we decided that the Plan's rules for coverage of the additional eyewear have not been met. Therefore, we decided that the Plan does not have to pre-approve one additional routine eyewear.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory tests provided on December 19, 2019 and December 23, 2019.
You asked the Plan to waive the copayments for laboratory tests. You say that you were told that you would not owe a copayment. 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 $5 copayment for lab services. You received laboratory tests on December 19, 2019 and December 23, 2019. Therefore, you are responsible to pay a $5 copayment per each visit. The total amount you owe is: $10. You have been asked to pay the total copayment amount of $10 for laboratory tests. Laboratory tests fall within the outpatient hospital 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 for laboratory tests provided on December 19, 2019 and December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental implant (D6010), panoramic x-rays (D0330), oral exam (D0160) and unspecified adjunctive procedures (D9999) provided February 7, 2019 to May 2, 2019.
You asked the Plan to pay for the dental services. You say that had you known that they did not participate with the plan you would have gone elsewhere. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the dental implant (D6010), panoramic x-rays (D0330), oral exam (D0160) and unspecified adjunctive procedures (D9999) provided February 7, 2019 to May 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered by a Federal provider on November 20,
2019.
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 the services are not payable.
The Plan must follow Medicare rules. The rules say that Federal providers are generally excluded from
participation in the Medicare program.
We looked at the file and Medicare rules. The file shows that the services were not urgent or emergent in nature
and were rendered by a Federal provider. 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
services rendered by a Federal provider on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for four extractions provided on May 21, 2019.
You asked the Plan to pay for the extractions. The Plan denied your request. The Plan says that you exceeded the number of allowed extractions for the year.
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 two extractions per calendar year. We looked at the file and Medicare rules. The file indicates the Plan has covered two extractions for the date of service of May 21, 2019. Therefore, we decided that the Plan does not have to pay for the additional four extractions provided on May 21, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRA scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is needed as a follow-up to the CTA from
September 2019. The Plan denied your request. The Plan says that there is no documentation of change in
condition, and there is no documentation that the CTA was inconclusive.
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 scan. Our reviewer says that the
requested scan is medically reasonable and necessary. Our physician reviewer found clearly there is sufficient
evidence both clinically and imaging-wise to reimage the intracranial circulation. The request for MRA of the
intracranial circulation is indicated and reasonable as this test may shed further light on the severity of the
known stenosis of the left vertebral intracranial artery and the remainder of the vertebra basilar system in this
patient with imbalance clinical symptoms. Also, MRI of the brain at the same sitting will be useful to
determine if there is evidence of acute/subacute ischemia within the brain stem on DWI.
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 scan have been met. Therefore, we decided that the Plan has to pre-approve
an MRA scan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery services.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 oral surgery services.