Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the bifocal lenses (CPT V2200) and the standard frames (V2020). We decided that the Plan does not have to pay for the anti-reflective coating (CPT V2750), high index glass or plastic lens (V2782) and refraction (CPT 92015).
You asked the Plan to pay for the post-cataract eyeglasses. You say that you were unaware that you had to be seen by an approved provider. The Plan denied your request. The Plan says that routine vision care services must be received from approved providers.
We decided that the Plan has to pay for the bifocal lenses and the standard frames provided on March 14, 2019.
The Plan follows Medicare rules. Medicare rules say that one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL are covered.
The file shows that you have a medical indication for which Medicare will cover conventional eyeglasses. The file shows the claim was billed with a diagnosis of age related cataracts, which is not a routine vision benefit. Therefore, we decided that the Plan has to pay for the bifocal lenses and the standard frames provided on March 14, 2019.
We also decided that the Plan does not have to pay for the anti-reflective coating, the high index glass or plastic lenses and refraction.
The Plan follows Medicare rules. Medicare rules say that that anti-reflective coating (V2750) are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating physician. When these features are provided as a beneficiary preference item and are billed with an EY modifier they will be denied as not reasonable and necessary. Medicare rules say that the use of high index glass or plastic (V2782, V2783) for indications such as light weight or thinness will be denied as a non-covered deluxe feature. Medicare rules say that Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. We looked at the file and the Medicare rules. Medicare only covers anti-reflective coating when documented by the treating physician as medically necessary. The file does not contain documentation from the treating physician to substantiate Medicare's coverage criteria for the anti-reflective coating. Medicare says the use of high index glass or plastic will be denied as a non-covered deluxe feature. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating, the high index glass or plastic lens and the refraction provided on March 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you do not have the needed level of care at home. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. While you may benefit from additional multiple therapies, your functional level does not require or indicate that this therapy must be provided in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.You asked the Plan to pre-approve a home ventilator (E0466). You say that you would prefer to use a ventilator for your condition.The Plan denied your request. The Plan says a home ventilator is not medically necessary.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuro muscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met.  The enrollee has severe COPD but there is no evidence of increased pCO2.  The pCO2 was normal on a recent arterial blood gas.  A home ventilator is therefore 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 home ventilator (E0466) have not been met.Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer handles and a power seat elevation feature.You asked the Plan to pre-approve a power seat elevation feature (E2300) and transfer handles (K0108). You say that you need a Group 3 power wheelchair and accessories.The Plan denied your request. The Plan says a power seat elevation feature and transfer handles are not medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 transfer handles and a power seat elevation feature.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 13, 2019 to January 10, 2020.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. The Plan also says that appropriate care could have been rendered/obtained at a lower level of care, or in the home.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that requiredthe specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 13, 2019 to January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drug testing.
You asked the Plan to pre-approve drug test. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show any signs or symptoms of misusing or abusing medicines or drugs.
The Plan follows Medicare rules. Medicare rules say that definitive urinary drug testing may be covered for symptomatic patients, multiple drug ingestion, patients with unreliable history, patients with substance abuse or dependence, or patients on chronic opioid therapy. 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 drug test. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested testing. Our physician reviewer found the records do not show any signs or symptoms of misuse or abuse of medications. There is no unexpected screening test for drugs of abuse to justify a quantitative drug test. The request does not meet the criteria for quantitative testing of multiple drugs. Therefore, this testing is not medically reasonable or 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 drug test have not been met. Therefore, we decided that the Plan does not have to pre-approve drug testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you do not have confidence with the in-network providers. You say that you would like to have this surgery done with this doctor. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 an outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). You asked the Plan to pre-approve the mandibular partial denture. You say that you really need a partial because you are unable to chew on either side of your mouth very well.The Plan denied your request. The Plan says the maximum count allowed per period 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.Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5214) is limited to one procedure every five plan years. The record shows that you received a mandibular partial denture on April 11, 2019, and your mandibular partial denture benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for a buttock abscess. The enrollee has undergone wound debridement and continues to receive wound care and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on February 14, 2020.You asked the Plan to waive the copayment forthe x-ray. You say that you have never been charged for an x-ray in thepast. 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 $20 copayment for x-rays and ultrasounds. You have been asked to pay a $20 copayment for the x-ray. The x-ray 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 forthe x-ray provided on February 14, 2020.Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator (FES).
You asked the Plan to pre-approve a functional electrical stimulator. You say that this device is an upgrade and will help you walk. The Plan denied your request. The Plan says the records show you do not have a spinal cord injury.
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 a functional electrical stimulator. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the applicable NCD, a FES device is only covered for use in patients with a history of a spinal cord injury when additional requirements for coverage have been met. In this case the enrollee does not have a history of a spinal cord injury, nor does the enrollee meet all of the other requirements for coverage in the NCD. Therefore a FES device would not be considered 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 a functional electrical stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.
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 the enrollee broke tooth #14 and needs a crown. 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 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 pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that the enrollee's root canal was completed on tooth #18, and a crown is now needed. The Plan denied your request. The Plan says core buildup 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 pre-approve a core buildup, including any pins when required (D2950), bone graft at time of implant placement (D6104), and fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve the core buildup, bone graft, and fixed partial denture sectioning. You say that you have a missing tooth that will aggravate the constant biting of your tongue. The Plan denied your request. The Plan says these services are not covered 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 a core buildup, including any pins when required (D2950), bone graft at time of implant placement (D6104), and fixed partial denture sectioning (D9120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve an oxygen concentrator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 an oxygen concentrator. Our reviewer says that the documentation does not support that the requested oxygen concentrator is medically reasonable or necessary. Our physician reviewer found you have a resting room air oxygen state of 97-98% with an occasional 96%. The documentation does not support that coverage criteria for supplemental oxygen are not met. Your oxygen saturations have not been below 96% on room air. Therefore, supplemental oxygen 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 an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two crowns (D2740 x2) provided on February 3, 2020.You asked the Plan to pay forthe crowns. You say that you contacted the Plan and asked for a list of in-network dentists. You also say that the Plan told you that you would be responsible for 50% of the cost for crowns.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay forthe two crowns (D2740 x2) provided on February 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT angiography you received on September 10, 2019.You asked the Plan to pay for the CT angiography. The Plan denied your request. The Plan says this is not necessary.The Plan follows Medicare rules. Medicare rules say that a CT angiography is only covered for the above indications, and is never covered for screening. 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 the CT angiography. Our reviewer says that the requested CT angiography was not medically reasonable and necessary. Our physician reviewer found that the enrollee has some cardiac risk and no documented cardiac symptoms. In this setting, management of cardiac risk is based on clinical risk parameters and basic lipid analysis. Treatment based on results of screening coronary calcium scoring has not been demonstrated to improve cardiac outcome incremental to that achieved by treatment based on standard clinical risk profiling and basic lipid analysis. Coverage criteria for coronary calcium scoring is not met since there are no documented covered indications for the procedure and since "The test is never covered for screening, i.e., in the absence of signs, symptoms or disease."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 CT angiography have not been met.Therefore, we decided that the Plan does not have to pay forthe CT angiography you received on September 10, 2019.