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

We decided that the Plan does not have to pre-approvethe crown and a root canalfor tooth #28.You asked the Plan to pre-approvethe crown and a root canal. You say that you swallowed the original crown and a root canal was not performed. You say that you are turned down for everything.The Plan denied your request. The Plansays your benefit has been exhausted for the 2020 plan year.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 also have a maximum benefit of two crowns and one root canal per calendar year. The Plan paid for two crowns and one root canal provided on March 12, 2020, which exhausted your benefit.Therefore, we decided that the Plan does not have to pre-approvethe crown and a root canal for tooth #28.Your complaint about the doctor lying and being fraudulentis 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.

You asked the Plan to pre-approve the maxillary partial denture. You say that you lost your dentures in the emergency room. 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, dentures are limited to one set every 5 years. The record shows that you received a maxillary partial denture on June 20, 2017, and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are unable to walk without orthotics. 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 foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous lysis procedure.

You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your request. The Plan says there is not enough proof the service will improve health outcomes.

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 requested services. Our physician reviewer found that you have chronic low back pain, and have failed back surgery syndrome. You have had 3 caudal epidural steroid injections without sustained relief. You are taking Percocet for pain. The requested procedure is considered an experimental/investigational technique because long term outcomes have not been shown to clinically significantly improve pain levels. Therefore, the request is deemed not medically necessary or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous lysis procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation.

You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that you feel this procedure is appropriate and medically necessary. The Plan denied your request. The Plan says you do not meet the medical necessity requirements for the x-ray of the jaw.

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 cone beam CT capture and interpretation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower partial denture and additional extraction.

You asked the Plan to pre-approve the upper and lower partial denture and additional extraction. You say that you have to eat your food crushed or pureed. You say that you need the services for your dental problems. The Plan denied your request. The Plan says the 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, you also have a maximum benefit of one extraction per year. The Plan pre-approved one extraction, which exhausted your benefit. Dentures are not listed as a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture and additional extraction.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve ultrasound services. You say that this enrollee resides in a nursing facility and cannot leave; therefore, the enrollee has no choice but to use this out-of-network provider. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.

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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the requested image guided radiation therapy (IGRT) is 
medically necessary. The Plan denied your request. The Plan says that the requested image guided radiation 
therapy (IGRT) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IGRT. Our reviewer says that the 
requested image guided radiation therapy (IGRT) is medically necessary. Our physician reviewer found the 
ASTRO model policy on IMRT describes IGRT in general terms: ?Image Guided Radiation Therapy (IGRT) 
utilizes imaging technology to modify treatment delivery to account for changes in the position of the intended 
target. IGRT is indicated for use in patients whose tumors are located near or within critical structures and/or in 
tissue with inherent setup variation, but does not specify when it is necessary. 
 
The NCCN guidelines for breast cancer address IGRT as follows: Verification of daily setup consistency is 
done with weekly imaging. When using certain techniques (i.e., prone breast) more frequent imaging may be 
appropriate. Routine use of daily imaging is not recommended.? 
 
For standard whole breast radiation for breast cancer, the patient can generally be set up without the use of 
IGRT using surface markers (i.e. tattoos). The fields are generally open tangential fields that are less 
susceptible to slight variations in position. 
 
For IMRT for breast cancer, IGRT is generally considered necessary, as the fields are modulated and daily-set 
up variation can impact the accuracy of dose delivery. 
 
Because of this general acceptance of necessity of IGRT with IMRT, the technical component of IGRT and 
IMRT are bundled together. They are generally verified on a weekly basis with portal imaging (which is 
different than IGRT which is daily image guidance). As use of IGRT with IMRT is within accepted standards 
or care, the request is medically reasonable and 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 IGRT have been met. Therefore, we decided that the Plan has to pre-approve 
image guided radiation therapy (IGRT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an out of network dental provider. 
 
You asked the Plan to pre-approve the dental service. You say that the requested provider is the only one in 
your area who works with disabilities and mental challenges. You sa The Plan denied your request. The Plan 
says the requested provider is not a participating provider with the Plan. The Plan also says there are 
participating dental providers available to provide the requested service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
consultation with an out of network dental provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four crowns (D2740 x4). 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. You say that the crowns are 
medically necessary. The Plan says this service is not covered under your 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 four 
crowns (D2740 x4).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha. You asked the Plan to pre-approve Repatha. You say that the enrollee previously tried other drugs with no improvement. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition by Medicare Part B. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha. Benefits for Repatha 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 pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of hypertension, end stage renal disease and dementia who presented to the acute hospital on 
09/24/2020 with acute encephalopathy related to a urinary tract infection. She was treated in the hospital with 
antibiotics as well as nephrology consultation. She is weak and deconditioned and has been evaluated by 
physical and occupational therapy. She is non-ambulatory and is total assist for transfers and activities of daily 
living. She is not able to participate in therapy sessions due to her cognitive decline. She has required physical 
and chemical restraints due to combativeness. Her rehabilitation potential is reported to be poor with a 
recommendation to discharge with 24-hour supervision but skilled services were not recommended. She is 
reported to be medically stable for discharge. 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services or skilled therapy services to be provided on a daily basis. This enrollee does not require the services 
on an inpatient basis, in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth cleaning of heavy deposits (D4355). 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental service is medically 
necessary. The Plan denied your request. The Plan says the requested service conflicts with a service that the 
enrollee previously received. 
 
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 the service is listed as covered, this 
service cannot be performed on the same day or less than 1 calendar year after an oral evaluation. The record 
shows that you received an oral evaluation on January 29, 2020. Therefore, we decided that the Plan does not 
have to pre-approve a tooth cleaning of heavy deposits (D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have been wearing orthotics for 20 years 
and need to continue. 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 foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical implant placement (D6013) and 
prefabricated abutment (D6056) for tooth #'s 23 and 26. 
 
You asked the Plan to pre-approve the surgical implant placement (D6013) and prefabricated abutment 
(D6056) for tooth #'s 23 and 26. You say that there is no bone structure in your mouth to place your bottom 
denture on. You say that you are unable to wear it and unable to eat. The Plan denied your request. The Plan 
says the 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 the 
surgical implant placement (D6013) and prefabricated abutment (D6056) for tooth #'s 23 and 26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown and prefabricated post and core for tooth #6. 
You asked the Plan to pre-approve the crown and prefabricated post and core. You say that the crown fell apart 
and you need to have it replaced. You say that the first procedure failed so the replacement should be covered. 
The Plan denied your request. The Plan says this service is only allowed one time every 60 months. 
 
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 also have a maximum benefit of 
one crown per tooth every five years. The Plan paid for a crown and prefabricated post and core provided on 
June 30, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve 
the crown and prefabricated post and core for tooth #6
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. You asked the Plan to pre-approve incontinence supplies. You say that you need the supplies. The Plan denied your request. The Plan says the services are not covered. The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper and lower denture.

You asked the Plan to pre-approve the dental items. You say that you received dentures that continuously broke despite getting them fixed. You say that you were advised to return the dentures and you would be able to get a new pair. You also say that this is being denied for maximum count allowed per period. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit 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 covered, the frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid for dentures that you received on October 3, 2019. The record also shows that the dentures you received prior to October 2019 were the ones that were damaged, thus allowing the Plan to pay for the set you received in October 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper and lower denture.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to provide sixty (60) minute psychotherapy (90837), forty-five (45) minute psychotherapy (90837) and thirty (30) minute psychotherapy (90832) with a Licensed Marriage and Family Therapist (LMFT).

You asked the Plan to provide psychotherapy with a LMFT. You say that you have received treatment from this provider for eighteen (18) months and do not want to disrupt the good bilingual therapy services that have been provided. The Plan denied your request. The Plan says LMFTs are not qualified Medicare Providers and are not allowed to bill Medicare, which is your primary insurance. There are in-network bilingual providers in your area that can provide this service.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy with LMFT have not been met. Specifically, the Plan has in-network providers who can provide the requested services in the requested language. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to provide sixty (60) minute psychotherapy (90837), forty-five (45) minute psychotherapy (90837) and thirty (30) minute psychotherapy (90832) with a Licensed Marriage and Family Therapist (LMFT).