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

We decided that the Plan does not have to pre-approve a men's shoe depth inlay (L3221).
You asked the Plan to pre-approve a men's shoe depth inlay. You say that this is necessary because one of your legs is shorter than the other, and it gives you back problems. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a men's shoe depth inlay (L3221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure Plus.
You asked the Plan to pre-approve Ensure Plus. You say that you have been declared as a failure to thrive adult. You say that you have cardiac vasopressor syncope, and that surgery would be extremely dangerous. You say that you are extremely thin and that the Ensure is needed to give you nutrients. The Plan denied your request. The Plan says nutritional supplementation is not covered under Medicare or your Plan contract.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Ensure Plus.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and panoramic
x-ray provided on January 5, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that
you cannot afford to pay for this entire bill. The Plan denied your request. The Plan says these services are not
covered. The Plan also says that you did not contact the Plan prior to this date of service to verify 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 the
problem focused limited oral evaluation and panoramic x-ray provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for transplant related expenses provided from July 27, 2020, through December 29, 2020.
You asked the Plan to reimburse you for the transplant related expenses. The Plan denied your request. The Plan says that receipts were not provided.
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 Plan has not provided the Plan's rules in the Evidence of Coverage to support this denial. Therefore, we decided that the Plan has to reimburse you for transplant related expenses provided from July 27, 2020, through December 29, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on December 17, 2020.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because you paid out-of-pocket and believe this service should be covered. The Plan denied your request. The Plan says you did not receive a referral for this provider and this provider is not in-network or contracted with Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Additionally, the record indicates that you did not receive a referral for therapy services as required by your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of current use of insulin as therapy.
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered if there
is evidence of insulin use.
The records do not contain evidence of insulin use. Based on this information, we decided that Medicare rules
for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and extraction (D7210) provided on January 23, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction. You say that these services should be covered. 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 pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and extraction (D7210) provided on January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider
on January 22, 2020.
You asked the Plan to pay for the laboratory test. You say that you submitted the appeal with medical records
and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was
required but not obtained.
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 laboratory test provided by an out-of-network provider on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided February 12, 2021
You asked the Plan to pay for the comprehensive exam. You say that you needed a new comprehensive exam in order to establish yourself as a patient at a new practice. The Plan denied your request. The Plan says this service was previously covered in 2019 and was therefore the service at issue was not yet eligible for coverage.
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 exam once every three plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that this service was previously covered on January 8, 2019. Based on this information, we determined that the Plan's frequency limits for coverage of the comprehensive exam had already been met at the time of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided February 12, 2021.
Your complaints about requiring a new in-network dentist and the Plan's coverage limits are not valid appeals for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November
27, 2020, through December 2, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that the bill was for the treatment of
COVID, and you should not have to pay out of pocket. 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 $285
copayment per day for days 1 through 7.
You have been asked to pay an $855 copayment for the inpatient stay. ($285/day x 3 days = $855). The
inpatient stay falls within the "Inpatient hospital 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 for the inpatient stay provided from November 27, 2020, through December 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says Dupixent is not covered under the enrollee's Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Dupixent.
Benefits for Dupixent 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0160,
A0130) received October 19, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you already paid the
bill and now the provider is charging more. The Plan denied your request. The Plan says the correct cost share
applied to the claim.
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 $300
copayment for Ambulance Services.
You have been asked to pay a $60.18 copayment for the ambulance transportation. The ambulance
transportation falls within the Ambulance Services benefit category. This is an amount less than or equal to the
required copayment for Ambulance Services. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
ambulance transportation (A0160, A0130) received October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper overdenture (D5864), a partial lower
overdenture (D5866), crowns (D2740 x 3), mini implants (D6013 x 2), extractions (D7140 x 2), and a filling
(D2393).
You asked the Plan to pre-approve the dental services. You say that you have received 4 letters to deny dental
coverage. You say that you signed up for dental plus and it did not help. You also say that you have asked the
Plan to send your mail to your post office box, but they have not done so. The Plan denied your request. The
Plan says the requested services are not covered under your dental benefit. The Plan also says that you are not
enrolled in the optional supplemental dental rider.
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 dental services are not
among those covered under this benefit. The Evidence of Coverage shows that you have coverage for
preventive dental services and x-rays only as you are not enrolled in the optional supplemental dental rider.
Therefore, we decided that the Plan does not have to pre-approve a partial upper overdenture (D5864), a partial
lower overdenture (D5866), crowns (D2740 x 3), mini implants (D6013 x 2), extractions (D7140 x 2), and a
filling (D2393).
Your complaint about the address that the Plan sends your mail to is not a valid appeal for medical coverage.
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF and a skilled nursing facility cannot provide the care this enrollee requires. The Plan denied your request. The Plan says the enrollee does not need or require oversight by a physician with specialized rehab training or a coordinated interdisciplinary team. Criteria for an inpatient rehab admission are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Durolane. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee has a condition that needs SNF care. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee presented to the acute hospital with severe bioprosthetic aortic valve stenosis. She is weak and deconditioned. She is walking up to 360 feet with a rolling walker with contact guard assistance, is at contact guard assist for transfers, and is at minimum assist for activities of daily living. There is no documentation that the enrollee requires skilled nursing services. Although the enrollee does require skilled therapy services, she does not need daily skilled services on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you have been enrolled in this plan for years. You say that now that you need dentures, they will not help you. You say that you are on a fixed income. You also say that you need help getting these dentures. The Plan denied your request. The Plan says the enrollee's dental coverage is limited to basic dental services. The Plan says that dentures are not listed as covered dental items. The Plan also says that you are not currently enrolled in the Comprehensive Dental 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, dentures are not among those covered under this benefit. The record shows that you are not currently enrolled in the Comprehensive Dental Plan. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for hearing aids provided on January 6, 2021.
You asked the Plan to reimburse you for the hearing aids. You say that your Plan has coverage for hearing aids with this provider and you should be reimbursed. The Plan denied your request. The Plan says that the full benefits will be applied once reprocessing has been done.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that you had coverage for the hearing aids based on the Plan's 2021 Evidence of Coverage. Therefore, we decided that the Plan has to reimburse you for hearing aids provided on January 6, 2021.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The Plan denied your request. The Plan says the requested Opdivo is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo. Our reviewer says that the requested Opdivo is not medically necessary. Our physician reviewer found the enrollee is diagnosed with metastatic ovarian cancer. There is no compendia basis or literature support for Opdivo in ovarian cancer. The request is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.