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

We decided that the Plan has to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says that the service are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's
failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records
in order to determine if the enrollee meets the Plan's hearing aids criteria. The enrollee had a hearing test in
February 2020 and the file says that the enrollee was supposed to have a hearing aid evaluation on May 24,
2020. The Plan has not requested or provided the hearing aid evaluation to determine if the Plan's criteria have
been met. Therefore, we decided that the Plan has to pre-approve hearing aids.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvea dental crown (D2790) of tooth #18.You asked the Plan to pre-approve the crown. You say that the crown is medically necessary.The Plan denied your request. The Plan says that coverage criteria is not met because the tooth is not sufficiently damaged.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown when the services are medically necessary and reasonable.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the crown is medically necessary. Our physician reviewer found due to the significant coronal breakdown of tooth #18 due to the large restoration and recurrent caries, coverage of the crown is medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met.Therefore, we decided that the Plan has to pre-approvea dental crown (D2790) of tooth #18.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown-porcelain fused to high noble metal for tooth #22 for the enrollee.You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that this was denied due to a clinically unacceptable root canal fill.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the services are medically necessary and reasonable. 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 crown is not medically reasonable and necessary for the enrollee in this case. The requested crown is for an endodontically treated tooth #22 which has a poorly condensed and short root canal filling. A properly completed endodontic fill should be a near the apical foramen as possible. In this instance, the canal fill is several millimeters short of the radiogaphic apex, and appears to be poorly condensed. Given the condition of the endodontic filling, which is poorly condensed and substantially short of the apex there can be no finding of medical necessity for the requested crown. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown-porcelain fused to high noble metal for tooth #22 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral exam (D0150) upper complete denture (D5110) panoramic x-ray (D0330) and cone beam CT scan (D0364) provided February 3, 2020.You asked the Plan to pay forthe dental services. You say that this was an extreme emergency and this dental office was the only office that was the most affordable.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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 forthe comprehensive oral exam (D0150) upper complete denture(D5110) panoramic x-ray (D0330) and cone beam CT scan (D0364) provided February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administer type drugs provided on February 5, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says these drugs are not covered under your Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administer type drugs provided on February 5, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on March 2, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that  The Plan denied your request. The Plan says that your request has exceeded the Plan benefit limit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive dental exams once every three plan years. We looked at the file and Medicare rules. The file indicates you received a comprehensive dental exam on October 7, 2019. Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for implant supported porcelain fused to metal crown (D6066) provided December 4, 2019.
You asked the Plan to pay for the dental services. You say that the only you picked up this additional upgraded dental insurance was to pay for this replacement crown. Otherwise you would have not have elected to pay extra money for services not covered. The Plan denied your request. The Plan says this service is not covered under the benefits 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. Per the plan contract basic crowns are covered. Implant supported crowns are not listed as covered under the description of benefits. 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 implant supported porcelain fused to metal crown (D6066) provided December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy services provided on February 18, 2020.You asked the Plan to pay forhome infusion therapy services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the codeis not payable by Medicare.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 code S9328 is not a valid code for Medicare purposes. S codes are uniquetemporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided that the Plan does not have to pay forhome infusion therapy services provided on February 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemyocardial perfusion imaging services.You asked the Plan to pre-approvethe myocardial perfusion imaging services. You say that the requested testing is medically necessary.The Plan denied your request. The Plan says the services requested are not needed because there is no evidence that there is a problem with the blood vessels that carry blood to the heart.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 myocardial perfusion imaging services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had some coronary risk, but no documentation or characterization of chest discomfort in the medical history, no documented cardiac physical exam, no documentation of an electrocardiogram and an inability to complete a treadmill test while wearing a mask. In the circumstance the documentation is not sufficient to support the medical necessity for nuclear stress testing. Screening nuclear stress testing has not been shown to improve cardiac outcome, evenin high risk patients. Therefore nuclear stress testing is considered appropriate only when there are symptoms that are suspicious for possible coronary ischemia.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 myocardial perfusion imaging services have not been met.Therefore, we decided that the Plan does not have to pre-approvemyocardial perfusion imaging services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electromyography study and a nerve conduction study with a tertiary level neurologist.You asked the Plan to pre-approvethe services with a tertiary level neurologist. You say that it is medically necessary to receive an electromyography study and a nerve conduction study with a tertiary level neurologist.The Plan denied your request. The Plan says the services can be performed by a non-tertiary and in-network provider.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 services with a tertiary level neurologist. Our reviewer says that a tertiary level of care is not considered medically reasonable and necessary in this case. Our physician reviewer found while theperformance an EMG/NCS would be clinically appropriate as part of the ongoing diagnostic evaluation of the enrollee, it is not necessary that this specific testing be done in the tertiary care setting. Rather, this is a service that could otherwise be provided within the enrollee's network and at a non-tertiary level of care. Having this procedure done in the tertiary level of care would not be consistent with having this testing furnished in a setting appropriate to the enrollee's medical needs and condition. Rather, provision of services at the higher care setting would exceed the enrollee's needs. The results of testing performed within the network can still be utilized by any other provider as part of the enrollee's ongoing clinical evaluation.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 with a tertiary level neurologist have not been met.Therefore, we decided that the Plan does not have to pre-approvean electromyography study and a nerve conduction study with a tertiary level neurologist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued physical therapy.You asked the Plan to pre-approvecontinued physical therapy. You say that you do not feel safe without physical therapy.The Plan denied your request. The Plan says your needs could be met with a home exercise program.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 continued physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records show that you have had extensive therapy. You have made progress in therapy and are participating in a home exercise program. The records do not indicate you require the unique skills of a professional therapist to safely and effectively provide treatment. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued physical therapy have not been met.Therefore,we decided that the Plan does not have to pre-approvecontinued physical therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you have medical issues
and need more transport rides so you can go to your appointments. The Plan denied your request. The Plan says
that you have exceeded your benefit limit.
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 twenty-four (24) 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 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis provided on February 20, 2020.You asked the Plan to pay fordigital breast tomosynthesis. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is not valid for Medicare purposes and is not payable.The Plan must follow Medicare rules. Medicare rules say that procedure code 77062 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay fordigital breast tomosynthesis provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73701) provided to the enrollee on December 7, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says CPT 73701 was billed by a different provider within the same group/specialty. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 73701 is "Computed tomography, lower extremity." We asked our coding 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 services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted was reviewed. The documentation noted was two copies of the same CT lower extremity, same date of service, and read by radiologist same day and time. We looked at this coder'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 radiology services (CPT 73701) provided to the enrollee on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to waive the coinsuranceforthe wheelchair and wheelchair accessory. We decided that the Plan does not have to waive the deductible for the wheelchair and wheelchair accessory. You asked the Plan to waive the cost share forthe wheelchair and wheelchair accessory. You say that you weren't informed this was a rental chair. You say that you were informed the Plan would pay 80% of the cost.The Plan says that the cost share applied correctly.We decided that the Planhas to waive the coinsuranceforthe wheelchair and wheelchair accessory.  We looked at your contract with the Plan. We did not see where the contract says you must pay 20% coinsurance for durable medical equipment. The Plan contract does not clearly disclose what amount between a $0 copayment and 20% coinsurance you wouldbe expected to pay for durable medical equipment. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsuranceforthe wheelchair and wheelchair accessory. We also decided that the Plandoes not have to waive the deductible for the wheelchair and wheelchair accessory.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 $198 deductible for Medicare Part B services. Until you have paid the deductible amount, you must pay the full cost for Medicare Part B services.Therefore, we decided that the Plan does not have to waive the $23.13 applied to meetthe deductible for the wheelchair and wheelchair accessory.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Shoulder (73221).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied yourrequest. The Plan says coverage criteria has not been met.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 the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found treatment of the cervical spine disease and plain x-ray imaging of the right shoulder are appropriate next steps at this point. The records do not support the need for an MRI.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Shoulder (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forassisted living care provided on February 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forassisted living care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the assisted living facility 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 forassisted living care provided on February 29, 2020 by an out of network (OON) provider.