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

We decided that the Plan does not have to pay for prism lens (V2715) and vision service (V2799) provided on August 29, 2020.
You asked the Plan to pay for Prism lens and vision service. You say that the services should be covered. The Plan denied your request. The Plan says the services provided are not covered benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The supplemental benefit does not include lens options such as tints, progressives, transition lenses, polish and insurance. We looked at the file and the Plan's rules. You received non-covered services. Based on this information, we decided that the Plan's rules for coverage of Prism lens and vision service have not been met. Therefore, we decided that the Plan does not have to pay for prism lens (V2715) and vision service (V2799) provided on August 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested bone marrow aspirate is
medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspirate is not
medically necessary.
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 bone marrow aspirate. Our reviewer
says that the requested bone marrow aspirate is not medically necessary. Our physician reviewer found the
enrollee is with chronic, debilitating lower back pain. Bone marrow aspirate remains experimental for use in
spine fusion surgery. More research is needed to show safety and efficacy. The requested bone marrow aspirate
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99309) provided on May 22, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service provided is not payable as the claim was not submitted timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for this service was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99309) provided on May22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76642) provided on August 18, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that the ultrasound should not have been an additional charge. The Plan denied your request. The Plan says the copayment was 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including Xrays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $77.93 copayment for an ultrasound. This service falls within the Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound (76642) provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and extraction (D7140) provided on September 9, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and extraction. You say that according to your dental rider, the exam and x-ray should have been covered in full. You also say that the extraction should have been covered by the Plan at 50%. The Plan denied your request. The Plan says the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that you were correctly charged for the extraction.
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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on April 22, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted. The Plan contract also says that you are responsible for a 50% coinsurance for extractions (D7140). Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and extraction (D7140) provided on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture.
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your
request. The Plan says this service exceeds the benefit allowance for dentures.
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 dentures once
every sixty months/five years.
Dentures were last received less than five years ago on May 29, 2020. Based on this information, we decided
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does
not have to pre-approve a complete maxillary and mandibular denture.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past
medical history of hypertension, hypothyroidism, diabetes and metastatic uterine sarcoma who presented to the
acute hospital on 01/05/2021 with progressive weakness. She was treated in the hospital with symptomatic
treatment in consultation with hematology and oncology. She is weak and unsteady and is working with
physical and occupational therapy. She is walking 80 feet with contact guard to minimum assistance with a
rolling walker and is minimum to moderate assist for transfers and activities of daily living. She is reported to
be medically stable for discharge.
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does require physical therapy and occupational therapy services but based on the medical records
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no
documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient
rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you for the routine eye exam (92014, 92015)
provided on July 14, 2020, by an out-of-network (OON) provider.
You asked the Plan to further reimburse you for the routine vision exam. You say that you would like this plan
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim processed
correctly, and no reimbursement is due.
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 routine
vision exam with a $75 allowance when services are received OON.
We looked at the file and Medicare rules. The file indicates that you received these services from an OON
provider and received a $75 reimbursement for the routine eye exam. The Plan's contract indicates you are
responsible for the remaining amount. Based on this information, we decided that the Plan's rules for coverage
of the routine vision exam have processed correctly. Therefore, we decided that the Plan does not have to
further reimburse you for the routine eye exam (92014, 92015) provided on July 14, 2020, by an out-ofnetwork (OON) provider.
Your complaint about the potential misinformation you received 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2954 and D3330) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approvedental services (D2954 and D3330) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 6, 2020 by an out of network (OON) provider.You asked the Plan to pay foranticoagulant management visit. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was 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 has network providers available who can provide 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 forthe medical services provided on August 6, 2020 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve car adaptive equipment for the enrollee.
You asked the Plan to pre-approve the equipment. You say that this is needed following a motorcycle accident. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve car adaptive equipment for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecrown restorations for teeth #22 and #27.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe teeth do not appear to have significant breakdown due to decay or trauma.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 services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is a lack of significant coronal breakdown due to caries or fracture. Crown restorations (D2751) for teeth #'s 22 and 27 do not meet the criteria for coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecrown restorations for teeth #22 and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional power wheelchair components (E2377, E2313, E2311).You asked the Plan to pre-approvepower wheelchair components. You say that the components are necessary.The Plan denied your request. The Plan says the additional components exceed medical necessity.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 power wheelchair components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that inthe medical records provided there is no documentation that the additional requested components meet Medicare requirements for medical necessity. Records indicate the enrollee has 4/5 right upper extremity strength and appears to have function to be able to control the power options using their own switches.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair components have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional power wheelchair components (E2377, E2313, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient services. You say that you would like reconsideration because the member signed documentation stating they had Medicare.The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.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 has network providers available who can provide 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 forthe medical services provided on July 6, 2020 by an out of network (OON) provider
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on April 2, 2020.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says it is
important to know which providers are part of our network because, with limited exceptions, while you are a
member of our plan you must use network providers to get your medical care and services. The only exceptions
are emergencies, urgently needed services when the network is not available (generally, when you are out of
the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. The Plan has network providers available who can provide the hearing aids. The Plan did not pre-approve
the service at issue. We found no exception that would require the Plan pay for these services. Therefore, we
decided that the Plan does not have to reimburse you for hearing aids provided on April 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 22, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forpractitioner visit. You say that your provider performed medically necessary services in good faith.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was 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 has network providers available who can provide 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 forthe medical services provided on June 22, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this service is experimental.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient level of care for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that this meets the medical necessity criteria for an observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented with a significant enough deficit, and would need enough resources that it is reasonable to expect that inpatient admission is appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for an inpatient level of care for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on August 5, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request.The Plan says the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on August 5, 2020.