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

We decided that the Plan does not have to pre-approvegingival irrigation and core build up services.You asked the Plan to pre-approvegingival irrigation and core build up services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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-approvegingival irrigation and core build up services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant removal (D6100) for teeth # 3, 4, and 9.

You asked the Plan to pre-approve the dental services. You say that the implants were placed while you were in
South Africa several years ago. You say that you have been experiencing significant discomfort for about 3
years. You say that you have been treated for multiple infections around the base of the implants. You also say
that you would like these services to be covered due to the frequent infections and their effect on your quality
of life as well as the possibility of infection becoming systematic. The Plan denied your request. The Plan says
implant removal is not listed as a covered service. The Plan also says that any services not listed 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. The Evidence of Coverage clearly states that any service not listed are
not covered. Therefore, we decided that the Plan does not have to pre-approve implant removal (D6100) for
teeth # 3, 4, and 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953),
guided tissue regeneration (D4266 x 2), bone replacement graft (D4263), a sinus augmentation (D7951),
implants (D6010 x 2), custom fabricated abutment (D6057), an implant supported crown (D6067), and
abutment supported crowns (D6059 x 2).

You asked the Plan to pre-approve the dental services. You say that you saw a periodontist while out of town.
You say that you were experiencing intense pain in the upper right quadrant. You say that upon returning home
you also saw your general dentist and periodontist. You also say that all specialists agree that the requested
services are essential medical-dental interventions. The Plan denied your request. The Plan says the requested
services are not listed as covered. The Plan also says that the medical needs do not expand the scope of
benefited procedures.

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. The Evidence of Coverage clearly states if a service is not listed, it is
not covered. Additionally, 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 preapprove
bone replacement graft for ridge preservation (D7953), guided tissue regeneration (D4266 x 2), bone
replacement graft (D4263), a sinus augmentation (D7951), implants (D6010 x 2), custom fabricated abutment
(D6057), an implant supported crown (D6067), and abutment supported crowns (D6059 x 2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 11,
2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you were informed you had to
come back because they saw something. You say that you were never told you had to pay a copayment. The
Plan denied your request. The Plan says the copayment applied correctly.

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 $40
copayment for each basic imaging service.

You have been asked to pay a $40 copayment for the ultrasound. The ultrasound falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The records show that the ultrasound
was ordered for diagnostic purposes. 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 ultrasound
provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Kit Sensor and Reader.

You asked the Plan to pre-approve Freestyle Kit Sensor and Reader. You say that due to her age the enrollee
has difficulty taking her blood glucose manually, therefore the Freestyle Libre system would be a much more
effective tool to track her blood glucose. The Plan denied your request. The Plan says the requested diabetic
supplies are not a preferred brand under the plan. The enrollee is not on insulin, diabetes is controlled and the
enrollee checks their blood glucose once a day and the request was made by the family for convenience.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of Freestyle Kit Sensor and Reader have not been met. Therefore, we
decided that the Plan does not have to pre-approve Freestyle Kit Sensor and
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on February 18, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Medicare
guidelines say that coverage of conditions related to your hospice diagnosis is the responsibility of the original
Medicare contractor, and not the managed care plan.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct

the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician's services provided on February 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for travel, meal, and lodging expenses received on November 1,
2018.

You asked the Plan to pay for travel, meal, and lodging expenses. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered
benefit.

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance.
However, the Plan offers a travel, meal, and lodging (TML) benefit that exceeds Medicare coverage. For that
reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of $10,000 per covered
transplant. This benefit only covers TML expenses for you and one companion for the evaluation and
transplant, not for follow-up or post-operative visits or transplant related inpatient admissions after you receive
your transplant. A transplant case manager will provide you instructions on how to submit your claim for TML
reimbursement, if eligible. Original itemized receipts (please keep a copy for your records), including all
pertinent information (member name and subscriber ID), must be submitted with your claim for reimbursement
within 90 days of your evaluation or transplant have been completed.

We looked at your request, the records in the case file, and the rules. Review of the file shows that travel, meals
and lodging (TML) expense reimbursement is limited to $10,000 per covered transplant. This benefit only
covers travel expenses for you and one companion for the evaluation and transplant, not for follow-up visits or
transplant related inpatient admissions, after you receive your transplant. The documentation shows that you
received corneal transplant surgery on October 15, 2018. The services you received for follow-up are noncovered.
Based on this information, we decided that the Medicare rules for coverage of travel, meal, and
lodging expenses have not been met. Therefore, we decided that the Plan does not have to pay for travel, meal,
and lodging expenses received on November 1, 2018.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete series of intraoral x-rays provided on July 20, 2020.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told that your Plan
covered a full mouth x-ray once per year. The Plan denied your request. The Plan says that the benefits for this
service have been satisfied and the frequency limitation has been exceeded.
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.
We looked at the file and Medicare rules. The 2020 EOC clearly states that intraoral x-rays are covered once
per calendar year. The records do not show that you have received any other intraoral x-ray over the 2020
calendar year. You reasonably believed that the complete series of intraoral x-rays would be covered. Based on
this information, we decided that the Plan's rules for coverage of the complete series of intraoral x-rays have
been met. Therefore, we decided that the Plan has to pay for the complete series of intraoral x-rays provided on
July 20, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON routine transportation services. You say that the medical records support the need for the requested routine transportation. The Plan denied your request. The Plan says you are requesting routine transportation services from a non-contracted provider. The Plan says that you are required to use a contracted transportation vendor. The Plan says that there are in-network providers in your area who are 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 routine transportation services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on December 30, 2019.
You asked the Plan to pay for the outpatient services provided by the Medical Center. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 outpatient services provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthoses (L1940, L2330).
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The physical examination does not document where the foot and ankle are unstable. The physical exam does
not reveal any manual motor testing of the bilateral lower extremity, ankle, or digits. The physical exam is
described in general terms that do not qualify or substantiate the request for custom fabricated bilateral ankle
ankle&#8208;foot orthoses. There is no documentation of an objective range of motion limitation in terms of degrees
of restriction present in the ankle, foot, and digits. In addition, there are no results of specific foot/ankle
instability maneuvers to confirm the presence of instability. Since there is no objective description of the ankle
instability, there is no justification for why the member needs to control the ankle or foot in more than one
plane. In fact, there is no description of which planes are in need of stabilization. Additionally, it is not noted
whether the enrollee is ambulatory, just that they use a wheelchair. Based on the documentation provided, the
Medicare criteria for these braces are not met. Therefore, we decided that the Plan does not have to pay for the
ankle-foot orthoses (L1940, L2330).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on February 8, 2020.
You asked the Plan to pay for the air ambulance services. You say that the air ambulance service was medically necessary. The Plan denied your request. The Plan says the enrollee was inappropriately transported by air ambulance to a more distant facility.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that the service was not medically necessary. Our physician reviewer found based on the documentation provided the health plan's denial should be upheld. The enrollee reportedly fell, injuring the right upper extremity. There is no evidence that the enrollee struck the head, was hemodynamically unstable, or was clearly having a stroke. It is unclear why the enrollee could not have been evaluated at the Medical Center, which appears to have been closer to the initial location. It is unclear why the enrollee could not have been transported to Shreveport via ground ambulance. There is no evidence that the use of air medical transport was medically necessary or 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 the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided on February 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided to the enrollee on February 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 services. Our reviewer says that the requested air ambulance services were not medically reasonable and necessary. Our physician reviewer found that the nearest facility with advanced stroke certification from the Medical Center, which was approximately 45 minutes from the transferring facility and which was closer by ground transportation than the Medical Center was by air transportation. The documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided to the enrollee on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided August 15, 2019, to August 19, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient care was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been discharged and gotten the stress test performed in the outpatient setting as she was stable.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was a then, 68-year old female who was admitted to the Medical Center on 8/15/2019 to 8/19/2019 for chest pain. The member has a medical history that includes hypertension, diabetes, cardiovascular accident, and hyperlipidemia. She had a recent right total knee replacement and was receiving physical therapy at a Nursing Home. The member reported chest pain for one day and two episodes of left-sided chest pain described as mild. The member's vital signs were within normal limits, her labs were within normal limits, and the chest x-ray had no significant findings. Cardiology evaluated the member. Cardiac enzymes were negative and echocardiogram finding was normal sinus rhythm. The member was admitted for continued monitoring, additional lab work, stress test. Intravenous normal saline was given. Her condition stabilized and improved and she was discharged home on 8/19/19.
The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided August 15, 2019, to August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 19, and retainer crowns (D6750) for teeth # 19 and 20.
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says pontic is not listed as a covered service. The Plan says retainer crowns are not listed as covered service. The Plan also says that any services no listed 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 19, and retainer crowns (D6750) for teeth # 19 and 20.