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

We decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226).
You asked the Plan to pre-approve the dental item. You say that you would like your eligibility for a new
denture to be moved up a month. You say that you are tired of going without a bottom denture. You also say
that you cannot afford to get a new partial on your own. The Plan denied your request. The Plan says dentures
are covered once every 5 years. The Plan also says that the frequency limit for this item has 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 and dentures are a covered benefit, the
frequency limit has been reached. The record shows that the Plan paid for a partial lower denture that you
received on July 6, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial lower
denture with flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental surgery (41899) and the reconstruction of the jaw (21248) to be provided in an out of network facility.
You asked the Plan to pre-approve the dental services. You say that your dentist feels you will have a better outcome, avoiding any emergency situation, having the dental surgery in a hospital setting. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that services performed out of network are not covered. The Plan says that the requested services are not an emergency. The Plan also says that the services can be performed in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dental surgery (41899) and the reconstruction of the jaw (21248) to be provided in an out of network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6245 x2) and two retainer crowns (D6740 x2).
You asked the Plan to pre-approve the pontics and retainer crowns. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two pontics (D6245 x2) and two retainer crowns (D6740 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy injection you received on January 21, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy injection. You say that this service was provided but the claim wasn't paid by the Plan. You want to know why you are receiving a bill from the provider. The Plan denied your request. The Plan says the amount due represents your coinsurance obligation. The Plan says that you were charged this coinsurance 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 chemotherapy drugs. You have been asked to pay 20% coinsurance for the chemotherapy injection. 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 for the chemotherapy injection you received on January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertiflex procedure remains experimental/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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before coverage can be approved. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 15, 2021.
You asked the Plan to pay for the office visit. You say that you attached the referral for review. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast revision surgery.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that breast revision is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has had multiple breast surgeries for benign lesions. She underwent reconstruction following nipple spring mastectomy with implant placements. She has had these revised due to scar tissue and had fat grafting and now desires further revision. The record indicates that the enrollee desires to have her breast higher on the chest wall and also to change the direction of nipple. The records support that the services are cosmetic in nature and 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-approve breast revision surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says the enrollee's current care needs can
continue to be met at the current acute care hospital.
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 that there is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from December 27, 2020, to January 11, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the enrollee was exposed to the coronavirus from a working nurse at the hospital which caused her to stay hospitalized. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $360 copayment for days 1-5 for inpatient hospital care. The enrollee has been asked to pay a $360 copayment for days 1-5 for the inpatient hospital services. This copayment applies regardless of the reason for the stay (or length of stay). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from December 27, 2020, to January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 26, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering physician is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on January 26, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis-adult (D1110) provided February 2, 2021.
You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you do not understand why the service is not covered. The Plan denied your request. The Plan says the services were not rendered by a participating provider and therefore 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. The Plan covers the periodic oral exam and dental cleaning when rendered by a participating provider.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis-adult (D1110) provided February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Generac GP6500 generator (E1399)
You asked the Plan to pre-approve the generator. You say that you disagree with the findings. The loss of power is frequent and common in the enrollee's home. The Plan denied your request. The Plan says these items are not considered durable medical equipment and are not covered.
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-approve a Generac GP6500 generator (E1399)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that, based on the provided medical records, the enrollee appears to be improving and stable and requires only additional short-term acute care treatment which can safely be treated at the current facility until able to transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available and covered at the current facility.
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-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four alveoloplasties in conjunction with extractions (D7310 x4) and four collections and applications of autologous blood concentrate products (D7921 x4).

You asked the Plan to pre-approve the alveoloplasties and collections and applications of autologous blood concentrate products. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these 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-approve four alveoloplasties in conjunction with extractions (D7310 x4) and four collections and applications of autologous blood concentrate products (D7921 x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610).
You asked the Plan to pre-approve the therapeutic parenteral drug. You say that a pre-authorization is needed for this service. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #'s 3 and 14.
You asked the Plan to pre-approve the pontics. You say that the pontics for tooth #'s 3 and 14 are not considered part of a multi-unit bridge, and need to be reprocessed. The Plan denied your request. The Plan says the documentation shows that tooth #'s 2,4, and 15 are missing, a bridge cannot be placed on missing teeth, and an implant supported bridge has been proposed. The Plan also says that the use of a pontic in conjunction with implant supported bridgework is not permitted.
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, any part of an implant supported bridge is not covered. Therefore, we decided that the Plan does not have to pre-approve pontics (D6245) for tooth #'s 3 and 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a free soft tissue graft procedure (D4277, D4278) provided on February 25, 2021.
You asked the Plan to pay for a free soft tissue graft procedure. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue 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 pay for a free soft tissue graft procedure (D4277, D4278) provided on February 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 24, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that the hospital didn't give you a Computed Tomography scan, so you do not believe the bill is fair. The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for emergency room visits. You have been asked to pay a $50 copayment for the ER visit. This copayment applies regardless of the extent of services you receive in the ER. 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 emergency room (ER) visit you had on March 24, 2021.