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

We decided that the Plan does not have to pay for the prophylaxis provided on October 27, 2020.

You asked the Plan to pay for the prophylaxis. You say that you would like to be reimbursed for the cleaning
because the Plan provides for cleanings twice per year. The Plan denied your request. The Plan says this benefit
has been exhausted.

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, you are limited to two routine
cleanings per calendar year. The record shows that you received one prophylaxis on February 19, 2020, and
another prophylaxis on June 22, 2020, and your routine cleanings benefit had been exhausted. Therefore, we
decided that the Plan does not have to pay for the prophylaxis provided on October 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 15, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because this was for your yearly women's exam.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist visits. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forthe lumbar sacral orthosis and shoulder orthosis provided to the enrollee on August 4, 2020.You asked the Plan to pay forthe orthoses. You say that these items should be covered.The Plan denied your request. The Plan says that that the billed code cannot be verified.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 contains a valid proof of delivery for the supplies provided in this case. The packing slip contains the same tracking number as the delivery ticket. These documents confirm the items that payment was requested for were delivered to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan has to pay forthe lumbar sacral orthosis and shoulder orthosis provided to the enrollee on August 4, 2020.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePhenytoin Sodium 100 mgcapsule (J8499).You asked the Plan to pre-approvePhenytoin Sodium capsule. You say that this treatment is necessary.The Plan denied your request. The Plan says rules for pre-approvalhave not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvePhenytoin Sodium 100 mg capsule (J8499)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea weight scale (E1639).You asked the Plan to pre-approvethe weight scale. You say that you would like reconsideration because you have stage 4 kidney failure.The Plan denied your request. The Plan says the records do not show that you have kidney failure and need dialysis.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  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.Therefore, we decided that the Plan does not have to pre-approvea weight scale (E1639).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the porcelain crown (D2740) provided.

You asked the Plan to pay more for the dental service. You say that you need a root canal and replacement crown sometime in 2019. You say that the provider's office quoted you for the procedures. You say that you were quoted $651. You say that you did not have the crown done. You say that you received a bill for almost double the initial quoted price. You also say that you were not advised of the change in price prior to receiving the service.The Plan denied your request. The Plan says there is a $1,000 annual allowance for non-Medicare covered preventive and comprehensive dental services. The Plan says the annual allowance has been exceeded. The Plan also says you are responsible for any amount above the dental coverage 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the annual allowance of $1,000 has been exceeded. The record shows that the Plan paid $1,000 towards the crown that you received on the date of service in this case, thus exhausting the allowance. The Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit.Therefore, we decided that the Plan does not have to pay more for the porcelain crown (D2740) provided.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit provided on August 10, 2020.You asked the Plan to waive the copayment foremergency room visit. You say that this visit was due to an incomplete treatment from a previous visit.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $120 copayment for emergency room visit.You have been asked to pay the allowed amount of $110.77, which is less than the $120 copayment for emergency room visit. Emergency room visit falls within the Emergency Care 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 foran emergency room visit provided on August 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formagnetic resonance imaging (74183) and 3D rendering (76376) provided on July 22, 2020.You asked the Plan to pay formagnetic resonance imaging and 3D rendering. You say that these services were performed by the physician.The Plan denied your request. The Plan says these services were previously billed and paid.The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.We find an additional unit of CPT code 74183 and 76376 are not supported in the medical record. The medical record only supports 1 unit each of CPT code 74183 and 76376, which was previously billed and paid for the same provider, beneficiary, and date of service. Based on this information, we decided that Medicare rules for coverage of magnetic resonance imaging and 3D rendering have not been met.Therefore, we decided that the Plan does not have to pay formagnetic resonance imaging (74183) and 3D rendering (76376) provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea resin-based composite (D2330) fortooth #11.You asked the Plan to pre-approvethe resin-based composite. The Plan denied your request. The Plan says this service exceeds the benefit allowance.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, resin-based composite is limited to one per 24 months per tooth. The record shows that you received a resin-based composite (D2330) on tooth #11 on May 10, 2019, and your resin-based composite benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea resin-based composite (D2330) for tooth #11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea transit option for a power wheelchair.You asked the Planto pre-approvethe transit option. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is only for use outside of 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 Plandoes not haveto pre-approvea transit option for a power wheelchair
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214).Youasked the Plan to pre-approvethe dental items. You say that the enrollee fell and broke your previous pair of dentures. You say that the enrollee is not able to chew properly. You also say that the enrollee needs new dentures.The Plan denied your request. The Plan says the requested services are covered once every 5 years. The Plan says that the frequency limits for the dentures have been reached.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 frequency limit of partial dentures onceevery 5 years has been reached. The record shows that the Plan paid for a partial upper denture that you received on June 10, 2017. The record also shows that the Plan paid for a partial lower denture that you received on October 31, 2016.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you don't trust in-network providers. The Plan denied your request. The Plan says there are additional in-network providers 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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pharmacogenetic testing provided on February 11, 2020.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says the coding is not supported.The Planmust follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We looked at the file and the rules. Testing for more than 1 CYP gene on the same date of service is non-covered.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe pharmacogenetic testing provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not appear to be stable enough for transfer as she is still requiring TPN and has not yet had a PEG placed. The patient requires additional short-term acute care services. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered at a later date when more appropriate.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided March 3, 2020.You asked the Plan to pay forthe acute inpatient hospital care. You say that the inpatient care was medically necessary.The Plan denied your request. The Plan says that the enrollee's needs could have been met at a lower level of care.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 the 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 inpatient care was reasonable given the presentation and the comorbid conditions.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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided March 3, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvesacroiliac joint radiofrequency ablation for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered not medically necessary and investigational.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. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is deemed experimental/investigational because of the wide variation in efficacy in published literature. Therefore, the request is considered 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvesacroiliac joint radiofrequency ablation for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided a participating provider on November 26, 2019.You asked the Plan to waive the copayment for an x-ray. You say that you got a bill 10 monthsafter. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for outpatient diagnostic tests/x-rays. You have been asked to pay a $15 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shingles vaccine.

You asked the Plan to pre-approve the shingles vaccine. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pre-approve the shingles vaccine.

Benefits for the shingles vaccine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided June 11, 2020 to
June 15, 2020.
You asked the Plan to pay for the SNF services. You say that these services were medically necessary. The
Plan denied your request. The Plan says rules for coverage were not met.
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 pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee did not meet severity of
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee's
needs could have been met at a lower level of care.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for skilled nursing facility (SNF) care provided June 11, 2020 to June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea non-invasive open ventilator.You asked the Plan to pre-approvethese 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. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Life2000 open ventilator system is not a true ventilator. It is intended for use while awake and active, rather than during sleep. There is inadequate evidence to support its efficacy in the treatment of chronic obstructive pulmonary disease (COPD). The services are not 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-approvea non-invasive open ventilator