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

We decided that the Plan does not have to pay for the implant maintenance procedures when prostheses are removed and reinserted, scaling and debridement in the presence of inflammation or mucositis of a single implant, three replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, three adjunctive procedures, and complete maxillary denture provided by an out-of-network provider, on May 8, 2019 and November 15, 2019.
You asked the Plan to pay for the implant maintenance procedures, scaling and debridement, three replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, three adjunctive procedures, and complete maxillary denture. You say that you were told by different plan representatives that you would be covered for these services. You also say that the provider advised you that you would be covered as well. The Plan denied your request. The Plan says the implant maintenance procedures, scaling and debridement, three replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, three adjunctive procedures are not covered benefits under your dental Plan. The Plan also says that the complete maxillary denture was provided by an out-of-network dentist.
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 implant maintenance procedures, scaling and debridement, replacement of semi-precision or precision attachment of implant/abutment supported prosthesis, and unspecified adjunctive procedures are not among those covered under this benefit. The contract also clearly states that services that are provided out-of-network are not covered by the Plan. The records show that you were advised by a plan representative that your plan provides coverage strictly for an in-network dentist. Therefore, we decided that the Plan does not have to pay for the implant maintenance procedures when prostheses are removed and reinserted, scaling and debridement in the presence of inflammation or mucositis of a single implant, three replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, three adjunctive procedures, and complete maxillary denture provided by an out-of-network provider, on May 8, 2019 and November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Golden Patriot 4 Wheel Heavy Duty Mobility Scooter.
You asked the Plan to provide a Golden Patriot 4 Wheel Heavy Duty Mobility Scooter. You say that the enrollee gets stuck in snow and on uneven surfaces so needs a new scooter with more power. The Plan denied your request. The Plan says the enrollee has been approved for a new heavy duty scooter but this request is for comfort and convenience for proposed use outside of the home.
The Plan follows Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The model at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a Golden Patriot 4 Wheel Heavy Duty Mobility Scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5260) purchased from an out of network provider on December 11, 2019.
You asked the Plan to pay for the hearing aids. You say that your original equipment broke down after 7 years and was unrepairable per the provider. You did go to TruHearing but you were not comfortable with the hearing aids they presented to you. The Plan denied your request. The Plan says hearing aids purchased from a non-contracted provider is not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a contracted provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5260) purchased from an out of network provider on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this drug is not covered for a diagnosis of anemia due to myelofibrosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee is being treated with Ruxolitinib, Darbepoeitin, and Danazol. Her most recent Hbg was 8.7. Recombinant human erythropoietin (rHuEPO) increases hemoglobin and hematocrit values and decreases the number of RBC transfusions. The review has determined that the documentation supports that the Aranesp is medically reasonable and necessary for the enrollee. The documentation supports that the Aranesp is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have been met. Therefore, we decided that the Plan has to pre-approve Aranesp for the enrollee.
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 pay for physician's services provided on November 18, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services rendered by non-participating providers, require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 29, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic manipulative treatment (98941) provided on October 21, 2019 through October 28, 2019.You asked the Plan to pay for the chiropractic manipulative treatment. You say that you would like reconsideration because this is a preventive measure to keep your back in good shape. The Plan denied your request. The Plan says this is maintenance chiropractor therapy that does not meet Medicare coverage criteria.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 the chiropractic manipulative treatment. Our reviewer says that the chiropractic treatments are supportive rather than corrective in nature and considered maintenance treatments. Our physician reviewer found medical necessity is not established as there is no evidence of significant affects to activities of daily living or evidence of significant functional loss.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 chiropractic manipulative treatment have not been met. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) provided on October 21, 2019 through October 28, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pre-approve Retacrit for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe off-label use of this drug is not covered.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found based on the enrollee's impaired renal function consistent with chronic kidney disease the documentation supports that the Retacrit is medically reasonable and necessary. Retacrit is safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have been met.Therefore, we decided that the Planhas to pre-approveRetacrit for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided to the enrollee on February 22, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation did not include the presence of an independent trained observer.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not support the services required the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on February 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rayaldee for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Rayaldee for the enrollee.
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 the admission. You say that this is medically necessary, as you can't get out of bed and feed yourself. The Plan denied your request. The Plan says you have been in the IRF since January 29, 2020, with no significant progress.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have a tracheostomy tube, complex wound care, unstable lab results or vital signs that need close observation or other SNF level skilled nursing need. Your functional level does not require skilled therapy services, with the specialized skill, knowledge and judgement of a qualified therapist to safely and effectively provide the treatment. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services, on an inpatient basis, in a SNF setting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network movement disorder specialist.
You asked the Plan to pre-approve these services. You say that you are unable to receive the care you need. The Plan denied your request. The Plan says the services are available from 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 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 a referral to an out-of-network movement disorder specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe L300 Go Foot Drop System and supplies provided on October 4, 2019.You asked the Plan to pay forthe Bioness Functional Electrical Stimulator. You say that the FESwas medically necessary.The Plan denied your request. The Plan says the enrollee does not have a spinal cord injury.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Bioness Functional Electrical Stimulator have not been met.Therefore, we decided that the Plan does not have to pay forthe L300 Go Foot Drop System and suppliesprovided on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of an erupted tooth (D7140 x 2).You asked the Plan to pre-approvethe dental service. You say that your dentist is not able to do the procedure in your assigned dental office. You also say that you have been to multiple dental clinics and none have been able to resolve your dental issue.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that supplemental dental benefits must be obtained through your primary care office.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 extraction of an erupted tooth (D7140 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider with enrollee.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from 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 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-approvea referral to an out-of-network provider with enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that you are experiencing pain and need the inserts. 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 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 (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) and a maxillary partial denture (D5225).
You asked the Plan to pre-approve the mandibular and maxillary partial dentures. You say that the enrollee is missing 6 teeth in total and is unable to chew due to the lower missing teeth. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, partial dentures are limited to one procedure every five plan years. The record shows that the enrollee received a maxillary partial denture (D5225) on February 18, 2019 and a mandibular partial denture (D5214) on January 14, 2019, and the enrollee's partial denture benefit is now exhausted. The Plan says that a prior authorization is not a guarantee of payment. The records also show that the enrollee's benefits changed between 2019 and 2020, and in the 2020 benefit year there is now a frequency limitation for dentures. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) and a maxillary partial denture (D5225).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have topre-approvea referral to an out-of-network hand surgeon.You asked the Plan to pre-approvethese services. You say that you do not want to see "the doctor".The Plan denied your request. The Plan says the services area available from 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 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. The Plan has referred you to the "in network doctor". 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-approvea referral to an out-of-network hand surgeon.Your complaint about "the doctor" 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.