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

We decided that the Plan does not have to pre-approvepartial upper denture (D5213) and partial lower denture (D5213).You asked the Plan to pre-approvethe denture services. You say that the enrollee has Down's Syndrome and had to get an emergency partial back in 2018. He really needs the partials and it is very difficult for him to chew.The Plan denied your request. The Plan says this request exceeds the benefit frequency limitations.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. This service is allowed once every 60 months (5 years) and records show that this service was last provided August 6, 2018.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-approvepartial upper denture (D5213) and partial lower denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefabricated post and core teeth 4 and 10 (D2952) root canal therapy tooth 10 (D3310) ponticteeth 4, 7 and 8, (D6240) retainer crown teeth 4, 6, 8, 10 and 11 (D6750) extraction teeth 5 and 9 (D7140).You asked the Plan to pre-approvethe dental services. You say that partial denture is necessary for eating. The enrollee is currently on a liquid diet due to having issue chewing food.The Plan denied your request. The Plan says the requested services are not covered benefits.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. Services not listed are not covered by the plan.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-approvefabricated post and core teeth 4 and 10 (D2952) root canal therapy tooth 10 (D3310) pontic teeth 4, 7 and 8, (D6240) retainer crown teeth 4, 6, 8, 10 and 11 (D6750) extraction teeth 5 and 9 (D7140).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on December 10, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that they didn't do the CT scan. You say that you shouldn't have to pay the charge.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrolleesin 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 $75 copayment for each visit for diagnostic radiology procedures. You have been asked to pay a $75 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the CT scan was performed. 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 forthe CT scan provided on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home glucose monitor test strips.

You asked the Plan to pre-approve home glucose monitor test strips. You say that you need test strips because of your medical condition. The Plan denied your request. The Plan says you are not diabetic and therefore not eligible for coverage of home blood glucose monitors and supplies.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at review the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home glucose monitor test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve home glucose monitor test strips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora parenchyma elastography ultrasound (76981).You asked the Plan to pay foran ultrasound. You say that medical necessity guidelines have been met.The Plan denied your request. The Plan says this is not a covered benefit.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 an ultrasound. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a liver disease, which may from time to time warrant liver imaging. The submitted documentation is insufficient to show that this was one of those times. There is no evidence that the enrollee had signs, symptoms, or ongoing treatment that warranted diagnostic imaging. Thedocumentation does not support that the performed US was medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultrasound have not been met.Therefore, we decided that the Plan does not have to pay fora parenchyma elastography ultrasound (76981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe additional 10 extractions (D7140) and 2 surgical extractions (D7210) provided on July 25, 2018.You asked the Plan to reimburse you forthe additional 12 extractions. You say that you received the dental services as a result of Sjorgren's disease. You say that Sjorgren's disease causes dry mouth and in turn causes dental caries. You say that the services should be covered since they were a result of Sjorgren's disease.The Plan denied your request. The Plan says the extractions are dental in nature. The Plan says 2 extractions per calendar year are covered. The Plan also says that the frequency limit has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are a covered service, the frequency limit of 2 extractions per calendar year has been exceeded. The record shows that the Plan has reimbursed you for 2 of the extractions that you received on July 25, 2018.Therefore, we decided that the Plan does not have to reimburse you forthe additional 10 extractions (D7140) and 2 surgical extractions (D7210) provided on July 25, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe walker provided on October 24, 2019.You asked the Plan to waive the coinsurance forthe walker. You say that you didn't ask for the walker. You say that the coinsurance should be waived.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.You have been asked to pay $17.13, which is 20% of the allowed amount for the walker. The allowed amount is $85.69 (20% x $85.69 = $17.13). The walker falls within the "Durable medical equipment (DME) and related 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 coinsurance forthe walker provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe office visit and foot x-ray provided on November 5, 2019.Youasked the Plan to waive the cost share forthe office visit and foot x-ray. You say that you did not know this was not in-network. You say that you are not able to pay.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that the Plan has a deductible amount of $183 for covered Part B services. Until you have paid the deductible amount, you must pay the full cost for covered Part B services. Office visits and x-rays are not excluded from the deductible. Your contract with the Plan says that you must pay 20% coinsurance for basic radiological services at an in-network provider. The item or service you asked the Plan to waive the cost share for fall within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your$183 deductible applies to office visits and x-rays.This cost sharing is a contractual obligation that had notbeen met at the time the office visit and foot x-ray werereceived on November 5, 2019.Therefore, $183 has been applied to meet your deductible. Since you met the $183 deductible, you have also been asked to pay $10.20, which is 20% of the allowed amount for the foot x-ray. The allowed amount is $51 (20% x $51 = $10.20). 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 cost share forthe office visit and foot x-ray provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe power operated vehicle high back seat.You asked the Plan to pre-approvethepower operated vehicle high back seat. You say that you need a high back seat on your approved scooter. The Plan denied your request. The Plan says when a scooter is provided it includes all of the accessories that are needed for the safe operation of thedevice.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the POV equipment package includes weight appropriate seating.Therefore, we decided that the Plan does not have to pre-approvethe power operated vehicle high back seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNova Memory Foam GEL cushion.You asked the Plan to pre-approve Nova Memory Foam GEL cushion. You say that your doctor advised you that you will need another spinal surgery and this cushion provides support for the whole spinal column and this is medically necessary for your comfort and well-being.The Plan denied your request. The Plan says this request exceeds coverage limits of 1 cushion every 5 years.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have Nova Memory Foam GEL cushion that you received on August 20, 2019. Since there is no evidence that the current Memory Foam Gel cushion was lost, stolen or destroyed, coverage is not allowed for replacement.Therefore, we decided that the Plan does not have to pre-approve Nova Memory Foam GEL cushion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued use of Yervoy and Opdivo for the enrollee.You asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysthe continued use of these drugs beyond four cycles is not supported in the medical literature.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination is supported by the NCCN Compendium for 4 cycles tobe followed by single-agent Opdivo (Nivolumab). The other compendia and FDA only support the combination as first line therapy and do not support it after previous treatment. The office visit note dated 3/23/2020 indicates the plan was for a PET scan and to transition to single agent Nivolumab (Opdivo) to be given in 4 weeks. Therefore the requested combination is not medically necessary and reasonable for the enrollee. The documentation does not support that the requested combination is safe and effectivefor the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drugs have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued use of Yervoy and Opdivo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendodontic therapy, root canal (D3330) prefabricated post care (D2954) and crown-porcelain fused to noble metal (D2750).You asked the Plan to pre-approvedental services. You say that you were told for all dental work like fillings, extractions and crowns you would pay 50% up to $2000. You feel that this should be covered since you were told this before signing up to the plan.The Plan denied your request. The Plan says the requested services are not covered benefits.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-approveendodontic therapy, root canal (D3330) prefabricated post care (D2954) and crown-porcelain fused to noble metal (D2750).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued stay at a skilled nursing facility (SNF).You asked the Planto pre-approvethe stay. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no complex wound care needs.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 the stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment beyond the last covered day. You do not have a tracheostomy tube, new enteral feedings, complex wound care, or other SNF-level skilled nursing needs beyond the last covered day. Your functional level does not require skilled therapy services with the specialized skill, knowledge, and judgement of a qualified therapist to safely and effectively provide medically necessary and reasonable in a SNF beyond the last covered day. The skilled nursing and skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF beyond the last covered day. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility, beyond the last covered day.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 stay have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued stay at a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay forSkilled Nursing Facility (SNF) service provided from November 1, 2019 to November 22, 2019.You asked the Plan to pay forSNF service. You say that you are a valid provider with Medicare.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because a valid Medicare identification was not submitted.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. The most current information from the Centers for Medicare and Medicaid Services (CMS) shows that the CMS Certification Number (CCN) for this provider has no associated expiration date and was effective for these dates of service. As such, we find that the Plan's denial based on no valid Medicare CMS Certification Number (CCN) is not supported. Therefore, we decided that the Plan has to pay forSkilled Nursing Facility (SNF) service provided from November 1,2019 to November 22, 2019.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 Plan does not have to waive the copayment forthe eye exam provided on November 8, 2019.You asked the Plan to waive the copayment forthe eye exam. You say that this was a routine eye exam,but the Plan is treating it as a diagnostic eye exam. You say that you shouldn't have to pay 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 $25 copayment for an in-network, Medicare-covered diagnostic exam.You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. 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 forthe eye exam provided on November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee was unresponsive in bed and did not appear to be breathing. You called 911 and when the responders arrived they evaluated and treated the enrollee. You say they discovered the enrollee's blood sugar was low and told you that you were right to call them becausethere was nothing you could have done to help. The responders asked the enrollee if he wanted to go to the hospital, however he said he felt better and wanted to stay home. You were advised by the responders to call them if it happened again. You say thatnow you do not know what to do since the Plan will not pay for the ambulance services. You asked the Plan to pay for their part of the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 2, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspinal manipulation (98941), extraspinalmanipulation (98943), and mechanical traction therapy (97012) provided from July 3, 2019 to July 15, 2019.You asked the Plan to pay forspinal manipulation, extraspinal manipulation, and mechanical traction therapy. You say that this was medicallynecessary.The Plan denied your request. The Plan says these services are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.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 spinal manipulation, extraspinal manipulation, and mechanical traction therapyOur reviewer says that the criteria for coverage of these services have not been met. Our physician reviewer found there are no submitted imaging studies. The documentation states that the enrollee exhibits a spondylolisthesis at L5 and advanced spinal degeneration of the lumbar spine. There is no evidence of a subluxation. The submitted chart notes/office visit notes do not reveal evidence of a subluxation per Medicare guidelines, meaning spinal manipulation is not covered. Extraspinal manipulation and mechanical traction therapy are not covered under Medicare rules.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal manipulation, extraspinal manipulation, and mechanical traction therapy have not been met.Therefore, we decided that the Plan does not have to pay forspinal manipulation (98941), extraspinal manipulation (98943), and mechanical traction therapy (97012) provided from July 3, 2019 to July 15, 2019.