Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thermal radiofrequency destruction for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary, as there was a procedure done on the right side which gave 95% relief. The Plan denied your request. The Plan says this 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee received the proper relief from prior injections in the left lumbar region to indicate this request. The review has determined that the left lumbar thermal radiofrequency destruction is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal radiofrequency destruction for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on January 5, 2021.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria for ambulance transport were not met.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. The trip report and the medical records provided do not show the enrollees condition required ambulance transport. The records state the enrollee indicated he had felt ill for about 4-days with vomiting and diarrhea. There was no shortness of breath, nausea chest pain, or additional complaints of pain. The enrollee stated he wanted to go to the hospital to be tested for Covid-19. The enrollee was hemodynamically stable with stable vital signs. There is not indication transport by means other than an ambulance would have endangered the enrollee's condition.
Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound-guided biopsy procedure you had on January 12, 2021.

You asked the Plan to waive the copayment for the biopsy. You say that you do not believe that the procedure you had was a surgery. You said that if you had known there would be a surgery copayment, you would have gone to a Veteran's Affairs (VA) hospital. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery. 

You have been asked to pay a $250 copayment for the biopsy. Biopsies are considered surgical 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 ultrasound-guided biopsy procedure you had on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental extraction (D7210) provided on January 12, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for a dental extraction. You say that you are not sure why it matters if your dentist opted out of Medicare. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue has opted out of 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. Therefore, we decided that the Plan does not have to pay for a dental extraction (D7210) provided on January 12, 2021, by a provider who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on March 15, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that both exams were necessary for your care. The Plan denied your request. The Plan says that your request exceeds the frequency limit for this service.

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 one limited exam to evaluate a problem per plan year. 

We looked at the file and Medicare rules. The file indicates the Plan has covered one limited oral exam for a date of service of January 26, 2021. The limited oral exam you are asking for reimbursement for is within the same plan year. Based on this information, we decided that the Plan's rules for coverage of the limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning seat cushion.
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a positioning seat cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need
additional trips to go to dialysis three times per week. The Plan denied your request. The Plan says the Plan
benefit does not cover more than 50 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit covers
up to 50 one-way routine transportation trips per year. Therefore, we decided that the Plan does not have to
provide coverage for additional routine transportation trips.
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 services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary or reasonable.
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 the patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. The Plan
denied your request. The Plan says SNF care is not medically necessary. The Plan says that the enrollee does
not need daily skilled care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs, The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a supervision level with functional mobility, including gait to 200 feet with a straight cane. The enrollee required varying assist with activities of daily living. The enrollee worked with speech therapy on dysarthria and dysphagia. There are no identifiable skilled nursing service needs. While there are still identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutment, includes placement teeth # 06, 08, 09 and 11 (D6057) and implant/abutment supported removable denture for edentulous arch, mandibular (D6111)
You asked the Plan to pre-approve the dental services. You say that you are appealing the decision to deny the medical services requested that are needed to restore your health. The Plan denied your request. The Plan says these services are not covered under the Plan 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. The health plan contract says that any service not listed is not covered. 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 custom fabricated abutment, includes placement teeth # 06, 08, 09 and 11 (D6057) and implant/abutment supported removable denture for edentulous arch, mandibular (D6111).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the application of Epifix.
You asked the Plan to pre-approve the application of Epifix. You say that there is an increased risk of infection without the skin substitute. The Plan denied your request. The Plan says that the enrollee's wound is already healing.
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 the application of Epifix. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the wound does not heal well and required debridement on the last visit on April 26, 2021. 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 application of Epifix have been met. Therefore, we decided that the Plan has to pre-approve the application of Epifix.
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 waive the coinsurance for three tooth extractions (D7140) provided
on March 4, 2020, by an out-of-network provider.
You asked the Plan to waive the coinsurance for the extractions. You say that you were told you were covered
for up to $1,000 a year. You feel the Plan should pay the full bill because you had not met your annual
maximum yet. The Plan denied your request. The Plan says while the Plan does cover a maximum of $1,000
for supplemental dental services each year, you are also responsible for 50% of the billed charges for out-ofnetwork
services up to this allowance. After you meet the $1,000 annual maximum, you are responsible for
100% of charges.
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 50%
coinsurance for preventative and comprehensive dental services received out-of-network.
You have been asked to pay 50% coinsurance for the tooth extractions. Tooth extractions fall within the
preventative and comprehensive dental services benefit category, and in this case were received from an out-ofnetwork
provider. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for three tooth extractions (D7140)
provided on March 4, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick urinary collection system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says this is being requested for a self-diagnosed problem.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a PureWick urinary collection system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) for tooth 7.
You asked the Plan to pre-approve core buildup for tooth 7. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered under the enrollee's dental 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 core buildup, including any pins when required (D2950) for tooth 7.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where currently receiving 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 the LTACH services have not been met. Specifically, there is no medically necessary services at an LTACH that the enrollee is not already receiving at their current level of care. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. You say that this will improve your independence and self-esteem. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that power seat elevation features are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.

You asked the Plan to pre-approve a power seat elevation feature. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid-circulating cold pad with pump (E0218).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity for requested service has not been established based on review.
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. The requested item is statutorily not covered. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid-circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for frames (V2020) received on August 27, 2020.
You asked the Plan to pay for frames. You say that you do not understand why the Plan denied payment for the
item. The Plan denied your request. The Plan says that the gender submitted does not match their system.
Medicare generally does not cover routine vision and eyewear services. The rules say that Medicare covers one
pair of eyeglasses after cataract surgery. The rules also say that Medicare plans must make reasonable and
diligent efforts to gather and forward information to the Independent Review Entity (IRE).
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of frames have been met. The Plan has not made reasonable and diligent efforts to gather and forward
to us information regarding their decision to deny your request. The record does not disclose exactly who the
provider at issue is, or their network status. The record does not clarify if the eyeglasses at issue were for postcataract
surgery. It is the burden of the Medicare Plan to substantiate the denial with evidence. The denial is not
substantiated based on the information provided, and we must find in your favor. Therefore, we decided that
the Plan has to pay for frames (V2020) received on August 27, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203, 99213) to be rendered by the
OON provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says that an in-network provider is available to provide the
requested service.
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 service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office
visit (99203, 99213) to be rendered by the OON provider.