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

We decided that the Plan does not have to pre-approve a lower partial denture (D5214).
You asked the Plan to pre-approve the dental item. You say that you were previously approved for upper and lower partial dentures. You say that the approval has since expired. You also say that you are unable to eat, or chew. The Plan denied your request. The Plan says the lower partial denture is not medically necessary. The Plan also says that the remaining teeth do not show healthy gums or bone support for the 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 the dental item 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 dental item. Our reviewer says that the service partial denture is not medically necessary. Our physician reviewer found the enrollee's dental record and radiographs indicate that since the radiographs were submitted the extraction of teeth # 17, 25, 26, 27 and 28 were carried out. The reviewer found that the only remaining mandibular tooth is # 19. Due to the lack of abutment support, the criteria for coverage for mandibular removable partial denture has not been met. 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 dental item have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had previously been to the emergency room and received treatment. You say that later when you were home you began to have a reaction to what you had been given at the hospital. You called for EMS and the responders came and evaluated you. You say that you were told by the responders that if they took you to the hospital, the hospital would not do anything for you. You say that you were told the symptoms were a reaction to your previous treatment at the hospital, and to drink water and that the symptoms would go away after a while. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit or the an x-ray provided on October 31, 2019.
You asked the Plan to waive the copayments for the specialist office and the x-ray. You say that you should not be charged for a follow-up visit procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $35 copayment per specialist visit and a $40 copayment for each basic imaging services (e.g., general x-rays or ultrasound). You have been asked to pay a $35 copayment for the specialist office visits and a $31.14 copayment for the x-ray, which is less than the standard copayment. The specialist office falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-ray falls within "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 copayments for the specialist office visit or the x-ray provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payforthe office visit services and x-rays (99203, 72040, 72070, and 72100) provided on September 24, 2019.You asked the Plan to pay forthe office visit services and x-rays. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit services and x-rays (99203, 72040, 72070, and 72100) provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rates for the bone replacement graft for ridge preservation and addition of two teeth to existing partial denture provided on November 4, 2019.
You asked the Plan to pay the in-network rates for the bone replacement graft and addition of two teeth to existing partial denture. You say that you delayed services with this provider until they were awarded in-network provider status. You also say that you clearly saw documentation in this provider's office of his in-network status with your insurance plan. 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 the in-network rates for the bone replacement graft for ridge preservation and addition of two teeth to existing partial denture provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 19, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says no documentation was received to support the diagnosis on the submitted order.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on November 26, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee was independent at home prior to the illness. The Plan denied your request. The Plan says no hands-on assistance is needed for mobility.
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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a modified independent to supervision level with functional mobility. The enrollee required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a diagnostic esophagogastroduodenoscopy (EGD).
You asked the Plan to pre-approve EGD. You say that you are appealing with records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee's gastroesophageal reflux symptoms went away after treatment and therefore Medicare criteria are not met.
The Plan follows Medicare rules. Medicare rules say that diagnostic EGDs are covered for esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy. 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 EGD. Our reviewer says that the enrollee meets Medicare criteria for the requested EGD. Our physician reviewer found the enrollee has esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of EGD have been met. Therefore, we decided that the Plan has to pre-approve a diagnostic esophagogastroduodenoscopy (EGD).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 14, 2019. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to the emergency room only to get a prescription 'refilled.' You say you do not agree with paying a $90 copayment for a refill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $90 copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room visit. 
 
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 visit provided on September 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dulera Inhaler.
You asked the Plan to pre-approve the inhaler. You say that the Dulera Inhaler is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this request is not covered under Medicare Part B because Dulera is a self-administered drug.
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 a Dulera Inhaler.
Benefits for the inhaler 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 200mg Votrient tablets.
You asked the Plan to pre-approve the Votrient. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says Votrient is not a covered benefit under Medicare Part B because it is a self-administered drug and is not the same active ingredient as an intravenous cancer drug.
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 200mg Votrient tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan eye drops.You asked the Plan to pre-approve the Lumigan. You say that you would like reconsideration as the Lumigan eye drops are medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the eye drops are not a covered benefit under Medicare Part B because they are self-administered.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 Lumigan eye drops. Benefits for the Lumigan may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee.
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the patient is more than 90 days between x-rays for a non-union fracture. The Plan denied your request. The Plan says that DME is not covered in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that an osteogenesis stimulator is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment withan E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not beenmet. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,  training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 25, 2019.
You asked the Plan to pay for genetic testing provided on March 25, 2019. You say that this claim should be paid. The Plan denied your request. The Plan says a treating provider did not order these tests. There are no records to show the enrollee had signs or symptoms that required this testing. The test is not FDA approved to manage any type of cancer. There is no indication the enrollee had cancer. There is no established relationship between the ordering provider and the enrollee. Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare requires providers to show services provided were ordered appropriately. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary. In this case, there were insufficient records provided to show the results of this testing would be used to determine a diagnosis or determine a treatment strategy for any disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion decompression device procedure.
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). You say that the enrollee will particularly benefit from this less invasive approach as compared to a more invasive procedure. The Plan denied your request. The Plan says Medicare considers Interspinous Process Decompression not medically reasonable and 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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show 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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion decompression device procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant (D6010).
You asked the Plan to pre-approve the dental implant. You say that this service is medically necessary. The Plan denied your request. The Plan says the Plan may not authorize any services or items that are not reasonable and necessary. The Plan also says that dental implants are not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 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 the dental implant. Our doctor says that there is insufficient information to support that the dental implant (D6010) is primarily focused on a medical condition. Our doctor found that the clinical notes were focused on providing an implant for tooth replacement for #20 which had been extracted due to extensive caries. There was a supplemental statement by the oral surgeon regarding a need to stabilize the replaced left temporomandibular (TM) joint by placing and restoring an implant in the area of #20. There has been no x-ray supplied that can show how many teeth are in occlusion, and no way to assess the overall occlusion to determine how significant the one premolar implant would be to the left side occlusion. It appears the primary focus is a service to treat structures supporting the teeth. 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 dental implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental implant (D6010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. 
 
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 Synthroid tablets.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.