Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says that an MRI 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. Our reviewer says that the requested MRI of the cervical spine is not medically reasonable and necessary. Our physician reviewer found that the medical records indicate that the enrollee has a history of upper extremity pain. The differential diagnoses include a shoulder related pathology versus a plexopathy. In this case, the requested MRI can be said to be reasonable and necessary as part of the evaluation of the enrollee's condition. Such imaging can be used to help further rule in/out the etiology of the enrollee's symptoms. 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 have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
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 waive the copayment for the CT scan provided on December 9,
2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were not expecting the $95
copayment because the handbook lists a $0-$95 copayment. The Plan denied your request. The Plan says you
have been asked to pay 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 $0 to
$95 copayment for Medicare-covered diagnostic radiology services (not including x-rays). $0 copayment for
mammography and ultrasounds. $95 copayment for all other diagnostic and nuclear medicine radiological
services.
You have been asked to pay a $0 to $95 copayment for the CT scan. The CT scan 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 for the CT scan provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 2, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis is medically necessary. The Plan denied your request. The Plan says the enrollee was contacted and indicated they received a phone call from the provider offering a back brace.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item. The Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the orthosis. As such no payment may be made for this item. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (card).
You asked the Plan to pre-approve the allowance for healthy food purchases and/or electricity, water and/or phone bill payments (card). The Plan denied your request. The Plan says you do not have a qualifying diagnosis, you do not require intensive care coordination and you do not have a high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.
We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (card).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve the total electric hospital bed. You say that the total electric hospital bed is medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and two periodontal scalings and root planings provided on December 7, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and scalings and planings. You say that the provider's receptionist was advised that the treating provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services are only covered by your Health Plan for in-network dentists.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, and two periodontal scalings and root planings provided on December 7, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee gradient compression stockings (A6531) for the enrollee.

You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered when used for management of venous insufficiency with venous stasis ulcers.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the stockings. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are pressure ulcers that are intact but are not related to venous insufficiency. The review has determined that the enrollee does not have a qualifying wound that would indicate these stockings. 

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 stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve knee gradient compression stockings (A6531) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on May 6, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you should not be responsible for the
MRI. The Plan denied your request. The Plan says you have been asked to pay 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 $150
copayment for all other diagnostic and nuclear medicine radiological services.
You have been asked to pay a $150 copayment for the MRI. The MRI 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
for the MRI provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction provided to you on December 9, 2020.
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this was not a routine
exam.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine refraction exam every two years.
We looked at the file and the Plan's rules. The requested eye exam was not a routine exam. Eye refractions are
only covered as part of a routine eye exam. Based on this information, we decided that the Plan's rules for
coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the
eye refraction provided to you on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6752 x2), and pontics (D6242 x2) provided on June 9, 2020.
You asked the Plan to pay for retainer crowns, and pontics. You say that you do not understand why the services were not paid by the Plan. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum was reached. You are responsible for 50% coinsurance for the services.
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. Based on this information, we decided that the Plan's rules for coverage of retainer crowns, and pontics have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum of $1000. You are responsible for a 50% coinsurance for the services. Therefore, we decided that the Plan does not have to pay for retainer crowns (D6752 x2), and pontics (D6242 x2) provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve dental care (specifically a deep cleaning (D4341) and crown (D2740) in excess of the $1,000 maximum allowance.

You asked the Plan to approve additional dental services. You say that you would like the $1,000 dental benefit to be expanded. You have already met this maximum but required additional services. The Plan denied your request. The Plan says they will only cover up to a maximum of $1,000 per year for comprehensive dental services. You have already met this maximum allowance for the year.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, there is an annual maximum allowance of $1,000 for comprehensive dental services. Any services in excess of the annual maximum allowance will not be covered by the Plan. The Plan provided documentation that you have already exceeded the maximum $1,000 annual allowance, which has been paid by the Plan. Therefore, we decided that the Plan does not have to approve dental care (specifically a deep cleaning (D4341) and crown (D2740) in excess of the $1,000 maximum allowance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2020 to May 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 had network providers available who could have provided 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 laboratory services provided on May 23, 2020 to May 26, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the surgery services. You say that you are requesting corrective surgery by a provider who has helped you previously. The Plan denied your request. The Plan says the provider is out of network
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 surgery services to be provided by an out of network (OON) provider.
Your complaint that your wishes were disregarded by your physicians is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier (D4266), guided tissue regeneration - nonresorbable barrier (D4267), and bone replacement graft for ridge preservation (D7953) provided on November 9, 2020.
You asked the Plan to pay for the guided tissue regenerations and bone replacement graft. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered benefits 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 for the guided tissue regeneration - resorbable barrier (D4266), guided tissue regeneration - nonresorbable barrier (D4267), and bone replacement graft for ridge preservation (D7953) provided on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that a wheelchair would give you the ability to travel with your wife. The Plan denied your request. The Plan says durable medical equipment is covered for use within the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the post and core in addition to crown and retainer onlay, or pay more for the addition of a tooth to existing partial denture and rebase maxillary partial denture provided on October 20, 2020 by an OON provider.
You asked the Plan to pay for the post and core in addition to crown and retainer onlay, and to pay more for the addition of a tooth to existing partial denture and rebase maxillary partial denture. You say that you were told that if you saw an out-of-network provider the Plan would cover 50% of the services. The Plan denied your request. The Plan says post and core in addition to crown and retainer onlay are not covered benefits. The Plan also says that the addition of a tooth to existing partial denture and rebase maxillary partial denture were rendered by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, post and core in addition to crown and retainer onlay are not among those covered under this benefit. The Plan contract also says that you are responsible for the coinsurance plus the difference between the billed amount and allowed amount for covered services received OON. Therefore, we decided that the Plan does not have to pay for the post and core in addition to crown and retainer onlay, or pay more for the addition of a tooth to existing partial denture and rebase maxillary partial denture provided on October 20, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two
implant supported crowns (D6066 x2).

You asked the Plan to pre-approve the custom fabricated abutments and implant supported crowns. You say
that you would like to appeal these services. The Plan denied your request. The Plan says these services are not
covered under your benefit package.

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 two
custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a history of diabetes. The documentation does not contain a blood glucose log. He is prescribed Lantus once daily and is not taking at least three shots of insulin daily. The criteria for coverage are not met and the CGM is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on November 17, 2020.
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on November 17, 2020.