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

We decided that the Plan does not have to pre-approve lower partial denture (D5212).
You asked the Plan to pre-approve the partial denture. You say that you had your partial done between 11/01/2019-12-23/2019. You were supposed to pick them up on 01/09/2020 but you were told it was no longer covered. You have no money to pay for this. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve lower partial denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens fitting (92310) routine ophthalmological
examination including refraction (S0621) provided September 6, 2019.
You asked the Plan to pay for the vision services. You say that you were advised by the plan that your eye
exam would be covered and request reconsideration. The Plan denied your request. The Plan says that the
service codes billed are not payable by Medicare and the provider was informed to submit a correct claim with
the correct service codes so the claim can be reprocessed for payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that the Plan's rules for coverage of the vision services have not been
met. Therefore, we decided that the Plan does not have to pay for contact lens fitting (92310) routine
ophthalmological examination including refraction (S0621) provided September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture.
You asked the Plan to pre-approve a partial upper denture. The Plan denied your request. The Plan says that
this service is allowed once every 60 months.
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 a partial
upper denture once every 60 months.
We looked at the file and Medicare rules. The file indicates you received a partial upper denture on August 13,
2015. Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture
have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve side rails (E0305).
You asked the Plan to pre-approve side rails. You say that the enrollee has a difficult time standing up and his
legs are weak and due to his age he uses a walker. The bed rails will assist him in getting up from bed. The
Plan denied your request. The Plan says bed rails are only covered under Medicare for use when medically
necessary on a hospital bed. The enrollee does not have a hospital bed and the bed rails will be for use on a
regular bed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Bed rails are only covered under Medicare for use when medically necessary on a
hospital bed. The plan has confirmed that the enrollee does not have a hospital bed and the rails are to be used
on a regular bed. Based on this information, we decided that Medicare rules for coverage of side rails have not
been met. Therefore, we decided that the Plan does not have to pre-approve side rails (E0305).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve debit card for allowance for healthy food purchases,
electricity, water or phone bill (S9986).
You asked the Plan to pre-approve the debit card for allowance for healthy food purchases, electricity, water or
phone bill. You say that you are requesting reconsideration of the denied service. The Plan denied your request.
The Plan says the enrollee does not meet the criteria as the enrollee does have two qualifying diagnoses but
does not require intense care coordination, has no high risk for hospitalizations or high risk for adverse health
outcomes.
Medicare generally does not cover for healthy food purchases or electricity, water or phone bill payments.
However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the plan's rules apply in
this case. The health plan contract specifically says to be eligible you must have one or more comorbid and
medically chronic conditions that are life threatening or significantly limit your health or general function. In
addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require
intensive care coordination.
Based on this information, we decided that Medicare rules for coverage of the debit card for allowance for
healthy food purchases, electricity, water or phone bill have not been met. Therefore, we decided that the Plan
does not have to pre-approve debit card for allowance for healthy food purchases, electricity, water or phone
bill (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided on October 10, 2019 by an out
of network provider.
You asked the Plan to pay for the shoulder orthosis (L3660). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says you did not request prior authorization.
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the shoulder orthosis provided on October 10, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of dental implants for teeth 22 and 27 (D6010).
You asked the Plan to pre-approve the dental services. You say that you are appealing because dentures will not work for you and your dental provider has recommended implants. The Plan denied your request. The Plan says the requested service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of dental implants for teeth 22 and 27 (D6010).
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided on May 29, 2019.
You asked the Plan to pay for the home health services. You say that this claim should be paid. The Plan denied your request. The Plan says that this was not billed with TOB 0329 so it is not payable.
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 has denied this claim due to the TOB reported being incorrect. However, based on the information submitted, we find that the evidence is sufficient to support that the use of TOB 0327 is appropriate in this case. The copy of the claim submitted shows that this is a corrected claim, which is in keeping with the reported TOB 0327 which is a replacement of a previous claim. The Plan did not indicate whether it had received a previous claim for this service, which is suggested by the fact that a corrected claim was submitted. It is not clear from the documentation that the plan's denial rationale is supported. Therefore, we decided that the Plan has to pay for the home health services provided on May 29, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath/shower chair, with or without wheels, any size (E0240).
You asked the Plan to pre-approve shower bath chair. You say that you feel you need the shower chair due to the lack of balance you have due to a medical condition. The Plan denied your request. The Plan says a bathroom seat is not considered primarily medical in nature and is considered a convenience item by Medicare.
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 bath/shower chair, with or without wheels, any size (E0240).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says your medical issues are stable.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 health services. Our physician reviewer found that you have been provided instruction on safety precautions and infection control. You have dyspnea with moderate exertion, poor vision and bladder incontinence. You can ambulate with a walker and assistance. Documentation indicates you have a private caregiver. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient beyond what was approved by the health plan. There are no complex wounds, IV medications, new enteral feedings or other skilled nursing need. The request for home health skilled nursing services are 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 health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot, insert, removable, molded to patient model, longitudinal arch support, each (L3010) and addition to lower extremity, varus/valgus correction, plastic modification, padded/lined (L2275), for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. This type of equipment is allowed when it is part of a brace. We do not see that you have/need a brace attached. Therefore, we decided that the Plan does not have to pre-approve foot, insert, removable, molded to patient model, longitudinal arch support, each (L3010) and addition to lower extremity, varus/valgus correction, plastic modification, padded/lined (L2275), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator retrial.
You asked the Plan to pre-approve a spinal cord stimulator retrial. You say that the service is necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that the implantation of spinal cord stimulators (SCS) may
be covered as therapies for the relief of chronic intractable pain.
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 spinal cord stimulator retrial. Our
reviewer says that the service is not medically necessary. Our physician reviewer found there are no
extenuating circumstances documented here. A repeat trial 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 a spinal cord stimulator retrial have not been met. Therefore, we decided that
the Plan does not have to pre-approve a spinal cord stimulator retrial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for teeth 29 and 31 (D2950).
You asked the Plan to pre-approve the dental service. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup for teeth 29 and 31 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair for the enrollee.
You asked the Plan to pre-approve the Group 3 wheelchair. You say that a Group 2 chair does not offer all the required power options. The Plan denied your request. The Plan says the enrollee does not have a neurological medical condition.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who meet the coverage criteria. 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 Group 3 wheelchair. Our physician reviewer found that the enrollee has a diagnosis of shortness of breath, muscle wasting and atrophy, and cognitive communication deficit. The documentation does not support that the enrollee has a mobility limitation that is due to a neurological condition, a myopathy or a congenital skeletal deformity. Therefore, the requested wheelchair is not medically reasonable and 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 Group 3 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided to the enrollee from July 30,
2019 to October 14, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says there was no authorization.
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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for dermatology services provided to the enrollee
from July 30, 2019 to October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ophthalmology services. You say that you are going blind and you need to see this doctor. The Plan denied your request. The Plan says there is no network deficiency for these services and alternate network providers were found.
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 ophthalmology services to be provided by an out of network (OON) provider.
Please contact the Plan for a list of in-network providers available for these services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan cannot hold the enrollee responsible for the 59 extra units of rotary wing air mileage provided on October 19, 2019.
You asked the Plan to pay for the 59 extra units of rotary wing air mileage. You say that the closest hospital was full and the next option was the facility the enrollee was transferred to. The Plan denied your request. The Plan says that there is lack of medical necessity for the transport to the receiving facility.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The record shows the enrollee did not request the receiving facility. The provider is a contract provider. The file does not show that the plan provided notice that the 59 extra units of rotary wing air mileage would not be covered. Under Medicare rules, this means the 59 extra units of rotary wing air mileage is considered approved by the plan. Therefore, we decided that the Plan cannot hold the enrollee responsible to pay for the 59 extra units of rotary wing air mileage provided on October 19, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the facility failed to obtain the necessary authorization. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 service 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 on November 8, 2019 by an out of network (OON) provider.