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

We decided that the Plan does not have to pre-approve the Ensure Plus.
You asked the Plan to pre-approve the Ensure plus. You say that you are appealing the denial because you have difficulty chewing. The Plan denied your request. The Plan says this item is not covered
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve the Ensure Plus.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services (01936) providedon October 28, 2019.You asked the Plan to pay forthe anesthesia services (01936). You say that the use of general anesthesia for this procedure was medically necessary.The Plan denied your request. The Plan says the use of general anesthesia for this procedure was not medically necessary.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 pay for the anesthesia services (01936). Our reviewer says that the use of general anesthesia for this procedure was not medically necessary. Our physician reviewer found the enrollee is with lumbar radiculopathy.He underwent a transforaminal epidural steroid injection (ESI), left L5/S1 under fluoroscopy. The procedure was performed under monitored anesthesia care (MAC).According to the anesthesiology record, the enrollee was documented to have an ASA 3 status. However, the submitted medical records did not support a diagnosis, condition, and/or symptoms that meet the enrollee's documented ASA 3 status or meet the Medicare criteria for coverage of MAC. There was nothing in the enrollee's record indicating that itwas medically necessary to have an anesthesiologist present during a left L5/S1 transforaminal ESI under MAC. The review has determined that it is not medically necessary or reasonable for this enrollee to have MAC during this procedure. 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 anesthesia services (01936) have not been met.Therefore, we decided that the Plan does not have to pay forthe anesthesiaservices (01936) provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like to see this specific doctor. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens enhancement services provided on January 6, 2020.You asked the Plan to pay for the lens enhancement services. You say that you had a stroke four years ago that resulted in impaired balance and issues with your right eye vision. You say that the doctor ordered the lens enhancements because they were needed and the Plan should honor his decision.The Plan denied your request. The Plan says the lensenhancement services are not a covered benefit.Medicare generally does not cover routine vision and eye wear 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 does not cover lenses when they include additional upgrades, extra charges, and/or any customizations.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you do not require daily skilled nursing and/or daily skilled rehabilitation services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Kit Freedom and Freestyle Lite test strips.You asked the Plan to pre-approveFreestyle diabetic supplies. You say that you are appealing based on medical necessity.The Plan denied yourrequest. The Plan says the denial authorization for these supplies is correct, because Freestyle is not covered by the Plan and you can use the preferred products of Accu-Chek or OneTouch.The Plan must follow Medicare rules. Medicare rules say that the Plan may specify brands and manufacturers as preferred and may limit medical equipment to only those preferred brands and manufacturers as long as the enrollee retains access to all medicallynecessary items. We looked at the file and Medicare rules. Freestyle brand diabetic supplies are not covered by the Plan. You can use the Plan's preferred brands of Accu-Chek or OneTouch. Based on this information, we decided that Medicare rules for coverage of Freestyle diabetic supplies have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Kit Freedom and Freestyle Lite test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genetic testing/hereditary cancer panel.
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your request. The Plan says very little clinical information was received about your medical condition.
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 panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have a malignancy associated with a genetic component, and the listed family history is not enough to warrant this genetic testing. 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve a genetic testing/hereditary cancer panel.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 23, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were informed this was a covered service. You say that you shouldn't be responsible for the 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 $265 copayment per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 ambulance transport provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wet and dry wipes.
You asked the Plan to pre-approve the wipes. You say that this is medically necessary for your frequent seizures during the day. The Plan denied your request. The Plan says these items are disposable, non-reusable hygiene items, and fall outside of the scope of coverage.
The Plan must follow Medicare rules. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 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. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve wet and dry wipes.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided
December 9, 2019 to December 10, 2019.
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered outpatient hospital visit. You have been asked to pay a $2,573.22 coinsurance (20% x $12,866.08 of the Medicare allowed amount) for the outpatient surgery provided. 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 outpatient surgery provided December 9, 2019 to December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the requirement is that the doctor submits records to show the reason(s) the procedure had to be done before it could be reviewed and/or approved.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD requires 80% pain relief from the diagnostic blocks. This was not achieved, as 0% pain relief was reported. The request 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 15, 2020.You asked the Plan to pay for the physician's service. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area 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 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 physician's services provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have pre-approve a Group 3 power wheelchair and attachments.You asked the Plan pre-approve these services. The Plan denied your request. The Plan says that your mobility needs could be met with a Group 2 power wheelchair.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have pre-approve a Group 3 power wheelchair and attachments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on January 24, 2020 by the out of network provider.
You asked the Plan to pay for the dental services. You say that the provider's office accepts your dental plan. You say that the specific provider that you saw caused you to not receive coverage for the services. You also say that you feel you did everything to your knowledge in order to line up your coverage with a dentist who would take your insurance. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says services that you receive out of network 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, dental services are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on January 24, 2020 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee August 15, 2019.
You asked the Plan to pay for an intermittent limb compression device. You say that the claim should be paid. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice and proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order orproof of delivery for the supplies provided in this case. Additionally, there is no itemized shipping/billing invoice. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You say that you need a full electric hospital bed so you can get in the bed. You need the bed to help you get up and down. This is not a convenience for you.The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.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-approvea total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 additional crowns, 11 core buildups, including any pins when required, 4 endosteal implants, 4 custom fabricated abutments, 4 abutment supported porcelain/ceramic crowns, and an occlusal guard.You asked the Plan to pre-approvethe 10 additional crowns, 11 core buildups, 4 endosteal implants, 4 custom fabricated abutments, 4 abutment supported crowns,and occlusal guard. The Plan denied your request. The Plan says these services are not covered by Medicare under any normal circumstances and are not covered by your 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, core buildup, including any pins when required, endosteal implant, custom fabricated abutment, abutment supported porcelain/ceramic crown, and occlusal guard are not among those covered under this benefit. The contract clearly states that porcelain/ceramic or porcelain fused to high noble metal crowns are limited to one tooth per year. The record shows that you have been approved for one crown and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve10 additional crowns, 11 core buildups, including any pins when required, 4 endosteal implants, 4 custom fabricated abutments, 4 abutment supported porcelain/ceramic crowns, and an occlusal guard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on July 3, 2019.You asked the Plan to pay for the dental services. You say that your dentist broke your tooth. You say you were sent to the provider in this appeal to get a root canal. You say that your tooth hurt the first time he started the bridge procedure. You also say you did not have the finances to get the other tooth capped.The Plan denied your request. The Plan says the fixed partial denture sectioning is not a covered service.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 fixed partial denture sectioning (D9120) provided on July 3, 2019.Your complaint about your dentist breaking your tooth 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 eyewear provided on December 6, 2019.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says that you must use a plan optical facility.
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 these services when received from a plan optical facility. We looked at the file and the Plan's rules. The file indicates eyewear was not received from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the  device (L8679).
You asked the Plan to pre-approve the device. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the device (L8679).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The plan says that the referring provider is also 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 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 lab work provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea heavy duty, extra wide, hospital bed.You asked the Plan to pre-approvea heavy duty, extra wide, hospital bed (E0303). You say that you need a bariatric bedThe Plan denied your request. The Plan says you do not weigh over 350 pounds.The Plan must follow Medicare rules. The rules say that if documentation does not justify the medical need of the type of bed billed, payment will be denied as not reasonable and necessary.We looked at the file and Medicare rules. You do not meet weight criteria for this type of hospital bed. Based on this information, we decided that Medicare rules for coverage of a heavy duty, extra wide, hospital bed (E0303) have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy duty, extra wide, hospital bed.