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

We decided that the Plan does not have to pre-approve a complete upper denture, a complete lower denture and house/extended care facility call for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is unable to chew her and foot and has weight loss. The Plan denied your request. The Plan says that these services are not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture, a complete lower denture and house/extended care facility call for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve a maxillary partial denture. The Plan denied your request. The Plan says that this is not a covered benefit of your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP battery backup.
You asked the Plan to pre-approve a CPAP battery backup. You say that you say you need a CPAP battery backup. The Plan denied your request. The Plan says alternative power sources are not considered durable medical equipment by Medicare.
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. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME. Medicare will not pay separately or make any additional payment for backup equipment. The supplier must ensure the beneficiary's medical needs for the equipment use will be met on a continuous and ongoing basis and have a plan in place to deal with any equipment failure/interruptions that may be life-threatening. Therefore, we decided that the Plan does not have to pre-approve a CPAP battery backup.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says the enrollee did not require skilled services.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that the enrollee had any identifiable skilled nursing or therapy service needs. This beneficiary 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants, and desensitizing medicine (D9910) for the upper right quadrant.
You asked the Plan to pre-approve the gingival irrigation and desensitizing medicine. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan also says that desensitizing medicine is not listed as a covered service either.
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 gingival irrigation and desensitizing medicine are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants, and desensitizing medicine (D9910) for the upper right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve treatments (D3310) for teeth # 5, 8, 9, 26, 27, and 31, porcelain with high gold content crowns (D2750) for teeth # 5, 26, 27, and 31, an upper partial denture (D5211), and a lower partial denture (D5110).
You asked the Plan to pre-approve the dental services. You say that the enrollee is missing many teeth. You say that his remaining teeth are either fractured or have recurrent decay. You say that the enrollee has tried fillings, but they have failed many times. You also say that full coverage is recommended. The Plan denied your request. The Plan says nerve treatments, porcelain with high gold content crowns, and partial dentures are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve nerve treatments (D3310) for teeth # 5, 8, 9, 26, 27, and 31, porcelain with high gold content crowns (D2750) for teeth # 5, 26, 27, and 31, an upper partial denture (D5211), and a lower partial denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vicks filters (A9270) to use with  vaporizer.
You asked the Plan to pre-approve the filters. You say that you are asthmatic and you suffer a lot of sinus congestion and you need the filters to change when the machine needs it. The Plan denied your request. The Plan says this item is not covered.
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, is an over-the-counter item 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 filters (A9270) to use with vaporizer.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve meals on wheels services.
You asked the Plan to pre-approve the meals on wheels services.. You say that you have COPD and have been advised by your provider not to leave the house due to being vulnerable to Covid-19 The Plan denied your request. The Plan says meals on wheels are 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. Meals on wheels does not serve a purpose that is primarily medical in nature. Meals on wheels 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 meals on wheels services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.
You asked the Plan to pre-approve medical nutrition therapy services. You say that the enrollee has protein calorie malnutrition, achalasia, dysphagia and needs dietician/nutritionist to prevent worsening of malnutrition. The Plan denied your request. The Plan says this request is not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed zoledronic acid and does not have a history of osteoporotic fracture. The Plan's required drug is not likely to be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 18, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you don't know why a CT scan was ordered. You say that you shouldn't have to pay the copayment. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for each advanced imaging service. The enrollee has been asked to pay $189.16, which is less than the standard $275 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthree hours a day of therapy is not needed, because medical illnesses are stable.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from PT and OT, but you do not require an intensive therapy program. The admission is not medically necessary based on current functional status, and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRetacrit for the enrollee.You asked the Plan to pre-approveRetacrit. The Plandenied your request. The Plan says that the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules and isn't covered based on available information.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 indenying the request to pre-approve Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary for the enrollee in this case. The enrollee has suspected VIPoma and possible myelodysplastic syndrome (MDS) and has anemia with iron deficiency and blood loss. You state they wish to avoid transfusions. While MDS is a medically accepted use of Retacrit per DrugDex, the enrollee has recently been treated with Ferric Carboxymaltose. This led to improvement in her iron studies and an increase in her hemoglobin from 8.8 on 2/11/20 to 9.3 on 3/10/20. Therefore, treatment of the underlying iron deficiency has led to improvement in her anemia. She is not receiving myelosuppressive chemotherapy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Retacrit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approveRetacrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe catheter equipment provided from January 3, 2020 to February 3, 2020.You asked the Plan to waive the coinsurance forthe catheter equipment. You say that you have never paid for the supplies before in the past. You say you cannot afford these supplies that you need. The Plandenied 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. You have been asked to pay $182.40 which is 20% of the allowed amount for the catheter equipment on each date of service. The allowed amount is $912.00. ($912.00 x 20% = $182.40). The catheter equipment falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based onyour 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 forthe catheter equipment provided from January 3, 2020 to February 3, 2020.Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCrown -porcelain fused to high noble metal (D2750) for tooth #4.You asked the Plan to pre-approvethe dental services. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the requested service is not listed as a covered 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.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-approveCrown -porcelain fused to high noble metal (D2750) for tooth #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrowns (D2750) and core build up (D2950) for teeth # 4 and 6.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says there is no evidence of a pathologic destruction by caries or trauma involving 3 or more surfaces or at least one cusp. The Plan says the crowns are not medically necessary. The Plan also says that core build up is not a covered 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 the dental 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the documentation shows tooth # 4 has an existing large amalgam on the buccal of tooth # 4 withDOB decay present, possibly previously restored on the DO surfaces. The documentation does not indicate a cuspal involvement on tooth # 4 and therefore is not medically reasonable and necessary. The reviewer found that tooth #6 has noted IFL surface decay, however there does not appear to be any significant pathologic destruction of the cusp. Therefore, a crown fortooth #6 is not medically reasonable and necessary either.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvecrowns (D2750) and core build up (D2950) for teeth # 4 and 6.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on January 17, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were told this was billed incorrectly and you should not pay a copayment. You say this is a financial hardship. 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 $375 copayment for each visit to an in-network outpatient hospital for Medicare-covered services. You have been asked to pay a $375 copayment for the colonoscopy. The colonoscopyfalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgicalcenters"benefit category. The medical record shows the colonoscopy was performed due to anal and rectal bleeding, which makes the colonoscopy diagnostic in nature.This means that you have been asked to pay the correct amount based on your contract withthe 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 forthecolonoscopy provided on January 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study for the enrollee.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has documented obstructive sleep apnea requiring BiPAP for resolution of sleep-disordered breathing. He was previously unable to tolerate BiPAP, but now wants to try again. There has been no substantial change in clinical status since the titration study in 2017, and there is no reason to expect the OSA has resolved. The requested sleep study is therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea sleep study for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveback-up battery for BIPAP (E1399).You asked the Plan to pre-approveback-up battery. You say that the plan had authorized a battery backup but now it has been damaged and you need the equipment again because the electrical energy system is compromised and you need the machine for your health.The Plan denied your request. The Plan says this item 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-approveback-up battery for BIPAP (E1399).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from July 30, 2019 through August 21, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that he could have left when the benefit period ended. You say that the copayment for 2 days wouldn't have been charged. The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20 and a $172 copayment per day for days 21-100.The enrollee has been asked to pay a $344 copayment for the SNF stay. Date of ServiceSNF DaysNumber of DaysCopaymentMember LiabilityJuly 30, 2019-August 18, 20191-2020$0$0August 19, 2019-August 21, 201921-222$172/day$344TOTAL:$344The SNF stay falls within the "Skilled nursing facility (SNF) care" benefitcategory. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe SNF stay provided from July 30, 2019 through August 21, 2019.