Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoe lift.You asked the Plan to pre-approve a shoe lift. You say that because of leg length discrepancy you need shoe lifts but cannot afford them.The Plan denied your request. The Plan says this item is not a covered benefit.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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve a shoe lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, eight extractions, complete maxillary denture, and partial mandibular denture provided on August 8, 2019 and August 12, 2019. You asked the Plan to pay for the panoramic x-ray, eight extractions, complete maxillary denture, and partial mandibular denture. You say that you were told that you qualify for the $500 rebate. The Plan denied your request. The Plan says these services are not covered under your dental plan. The Plan also says that you do not qualify for the $500 rebate because you do not have a dental supplemental policy. 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 panoramic x-ray, eight extractions, complete maxillary denture, and partial mandibular denture provided on August 8, 2019 and August 12, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an upper eyelid blepharoplasty.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when specific criteria
are met.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has complaints of eyelids
dropping in front of his vision. The submitted photographs demonstrate findings that are consistent with the
examination and visual field results. The enrollee has dermatochalasis and MRD measurement of two
millimeters in the right eye and 1.5 millimeters in the left. Automated visual field tests showed superior visual
field defect to 25 degrees for both eyes and improving to 50 degrees with taped eyelids. Photographs
demonstrated bilateral upper eyelid dermatochalasis consistent with examination results. The criteria for
coverage of the blepharoplasty are met and the services are reasonable and medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve
an upper eyelid blepharoplasty.
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: 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary.
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 enrollee is with a past medical history of celiac disease who presented to the acute hospital on 0/6/12/2020 with an acute stroke with left-sided weakness. She was treated in hospital with aspirin, Plavix and Coumadin. She was also found to have Clostridium difficile colitis and was treated with oral vancomycin. She is weak on the left side with a left visual field impairment and is working with physical and occupational therapy. She is walking 750 feet without an assistive device but she is unsteady. She is contact guard assist for transfers and activities of daily living. She is medically stable. Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is no indication that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (31652, 31624, 31628) provided on September 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 31652, 31624, and 31628 are not supported in the medical record. Specifically, the records provided show that these services were provided on September 25 2019 The records do not show that the services were performed on September 24, 2019. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (31652, 31624, 31628) provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on November 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to make additional payment for the porcelain crown provided on March 11, 2020.
You asked the Plan to make additional payment for the crown. You say that you had no way of knowing that
your plan only covered silver crowns and not porcelain crowns. The Plan denied your request. The Plan says
that composite resin white restorations on a posterior tooth are not covered. The Plan also says that the Plan
will pay only the applicable amount that it would have paid for an amalgam (metal) restoration.
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.
You were referred for the crown by a contract provider. The file does not show that the Plan provided notice
that the porcelain crown would not be covered. The contract does not clearly state that only a silver crown
would be covered. The records also do not show that you were made aware that only a silver crown would be
covered, and you would be responsible for paying the difference. Under Medicare rules, this means the crown
is considered approved by the Plan. The 50% coinsurance should be applied to the total amount of the crown,
and not the reduced allowed amount. Therefore, we decided that the Plan has to make additional payment for
the porcelain crown provided on March 11, 2020. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the spinal canal.
You asked the Plan to pre-approve an MRI of the spinal canal. You say that the requested MRI of the spinal canal is medically necessary. The Plan denied your request. The Plan says the requested MRI of the spinal canal is not medically necessary.
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 an MRI of the spinal canal. Our reviewer says that the requested MRI of the spinal canal is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is reported to have back pain, for which MRIs have been ordered. No detailed history of the enrollee's back pain is noted. Comprehensive examinations of the spine, lower extremities, musculoskeletal system and neurologic system are not documented. The enrollee attributes her back pain, as well as many other pains, to lipomas. The documentation is insufficient to show that the requested MRIs are medically necessary and reasonable. 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 MRI of the spinal canal have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the spinal canal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 25, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says services from non-participating providers are not covered under the enrollee's plan unless they are authorized by the Plan before the services are provided.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam, problem focused (D0140) and periapical, first x-ray (D0220) and periapical, each additional x-ray (D0230) provided February 5, 2020.You asked the Plan to pay for the dental services. You say that you request reconsideration since you are allowed preventive x-rays at least once a year so please consider allowing the periapical x-ray. The exam was to determine overall health of your teeth.The Plan denied your request. The Plan says this services provided was to treat a known issue and to diagnose a problem and were not preventive and is therefore 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 pay for limited oral exam, problem focused (D0140) and periapical, first x-ray (D0220) and periapical, each additional x-ray (D0230) provided February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoe and accessories for your contralateral foot.
You asked the Plan to pre-approve a shoe and accessories for your contralateral foot. You say that the
requested shoe and accessories are medically necessary. The Plan denied your request. The Plan says these
items are not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover convenience items or items that do not serve a
direct medical purpose. Medicare does not cover the requested shoe and accessories for your condition.
Therefore, we decided that the Plan does not have to pre-approve a shoe and accessories for your contralateral
foot.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April
8, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were advised that
you needed your ears cleaned but were never told there would be a charge for the service. You say you would
not have had it done if you had known about the charge. 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 $45
copayment per specialist visit.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the specialist office visit provided on April 8, 2020.
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 admission to LTACH is needed for the
enrollee to provide care for the enrollee's pancreatic cancer, retinal disease, gangrene in one foot, and very low
blood pressure. The Plan denied your request. The Plan says You can stay where you are until you are able to
safely be cared for at a different level of care. Your breathing needs are being met at your current facility. You
may continue to get care at the current hospital until you are ready for discharge to another level of care.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by a non-participating provider. 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 were rendered by a non-participating provider without 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 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 the medical services provided on August 14, 2019 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, two endosteal implants, and sinus augmentation provided on January 17, 2019 and February 19, 2019.You asked the Plan to pay for the cone beam CT capture and interpretation, two endosteal implants, and sinus augmentation. You say that you are on a fixed income and need help paying this bill.The Plan denied your request. The Plan says these services are not covered under the 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 for the cone beam CT capture and interpretation, two endosteal implants, and sinus augmentation provided on January 17, 2019 and February 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 99 additional non-emergency medical transportation trips.You asked the Plan to pre-approve the additional trips. You say that you are requesting unlimited transportation rides to and from your doctor appointments. You have no more rides and do not want to die due to not getting to your doctors for your heart failure.The Plan denied your request. The Plan says this request exceeds the benefit limitation.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve 99 additional non-emergency medical transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office call provided on February 13, 2020. You asked the Plan to waive the copayment for an office call. You say that you were told that you would not have a copayment for this. 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). Your contract with the Plan clearly says that you must pay a $5 copayment for physician/practitioner services/PCP. You have been asked to pay a $5 copayment for an office call. Since physician services were provided, the correct copayment has been applied. An office call falls within the physician/practitioner services/PCP benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office call provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 6, 2020.You asked the Plan to waive the copayment for an outpatient surgery. You say that you shouldn't have to pay for this because it happened a month ago and it was the doctor's fault. 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).Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery. You have been asked to pay a $400 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 6, 2020. We note your complaint about the doctor making a mistake which caused you to get another surgery. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.