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

We decided that the Plan has to pre-approve a mandibular partial denture (D5214).

You asked the Plan to pre-approve the denture. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not medically necessary.

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 denture
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 denture. Our reviewer says that the
requested services are medically reasonable and necessary. Our physician reviewer found a review of your
dental records and x-rays indicate multiple missing mandibular teeth. The remaining teeth have adequate bone
to support to stabilize and retain a partial denture which would provide adequate masticatory function.

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 denture have been met. Therefore, we decided that the Plan has to preapprove
a mandibular partial denture (D5214).

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 pre-approve a lower partial denture. 
You asked the Plan to pre-approve these services. You say that you misplaced your lower denture. The Plan 
denied your request. The Plan says the services are not covered. 
 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. It is noted that dentures were covered in the 2020 Plan contract; 
however, the contract for 2021 does not cover these services. Therefore, we decided that the Plan does not have 
to pre-approve a lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unlisted evaluation and management service to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the unlisted evaluation and management service. You say that it is necessary to get approval because it will be hard to pay for the surgery expenses on a fixed income. The Plan denied your request. The Plan says the provider is out-of-network.

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 the unlisted evaluation and management service to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says that this is not medically necessary.
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 Orthovisc. Our reviewer says that Orthovisc is medically reasonable and necessary in this case. Our physician reviewer found that the records show that this enrollee meets criteria for an Orthovisc knee injection. She has knee degenerative joint disease and has had physical therapy, medications, and steroid injections. Therefore, Orthovisc is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have been met. Therefore, we decided that the Plan has to pre-approve Orthovisc.
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 pre-approve a cone beam CT image capture (D0383) and surgical
stent (D5982).

You asked the Plan to pre-approve the cone beam CT image capture and surgical stent. You say that the codes
and procedures that were denied are the latest, modern dental technology available and should be covered for a
successful dental implant. The Plan denied your request. The Plan says these services are not covered under
your benefit 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
cone beam CT image capture (D0383) and surgical stent (D5982).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair lift and swing for a vehicle.

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 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 items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a power wheelchair lift and swing for a vehicle.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient physician services (99239, 99233, 99232) provided from March 10, 2021 to March 12, 2021.

You asked the Plan to waive the deductible for the inpatient care. You say that you were admitted to the hospital for an emergency procedure, and you did not have a choice in which physician at the facility provided the services. You feel they should be covered in full. The Plan denied your request. The Plan says you had not met your deductible at the time of services, and a deductible applies because the services were provided out-of-network.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for out-of-network inpatient physician services.

The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-network inpatient physician services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network physician services. You state that these services were emergent, however there is no indication in the record that these services were provided following a trip to the emergency department or that any emergency care or ambulance services were provided during or immediately before this visit. The provider in this case is out-of-network, and therefore the deductible applies. This cost sharing is a contractual obligation that had not been met at the time the inpatient care was received on March 10, 2021 to March 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the inpatient physician services (99239, 99233, 99232) provided from March 10, 2021 to March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA, nerves innervating the sacroiliac joint, with image guidance (CPT code 64625).
You asked the Plan to pre-approve the services. You say that your sacroiliac (SI) injection has worn off and you are having pain in your low-back and buttocks which is not allowing you to walk very far. The Plan denied your request. The Plan says it is not medically necessary to have this procedure at the SI joint.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not clearly show that the Si joint is the pain generator. Also, SI joint RFA remains experimental 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA, nerves innervating the sacroiliac joint, with image guidance (CPT code 64625).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 3, 2020. You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says no medical records were provided to support the services rendered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the file shows that the laboratory results were not provided for review in this case. The record shows that the Plan made multiple attempts to secure these medical records, without success. Without the laboratory results of the tests at issue, we cannot determine if Medicare criteria are met in this case. This means that the laboratory testing at issue in this appeal is not proven to be provided not solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 3, 2020.
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 LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.

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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.

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. 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 waive the copayment for a continuous glucose monitor (K0553, K0554).

You asked the Plan to waive the copayment for the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to waive the copayment for a continuous glucose monitor (K0553, K0554).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
billed with an appropriate secondary diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that certain secondary diagnosis codes must be
reported when billing for ground ambulance services.

We looked at the file and Medicare rules. The documentation does not show that the ground ambulance
services were billed with a required secondary diagnosis code. 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 pay for the ambulance services provided on February 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF)
care provided from January 12, 2021, through February 11, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.

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 $0 copayment per day, per admission for days 1-20 and a $172 copayment per day, per admission for days 21-100, for skilled nursing facility (SNF) care. You have been asked to pay $4,472 ($172 copayment x 26 days) for the skilled nursing facility care provided. You previously received skilled nursing care which is part of this benefit period. 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 inpatient skilled nursing facility (SNF) care provided from January 12, 2021, through February 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic hearing test provided on
February 5, 2021.
You asked the Plan to waive the copayment for the diagnostic hearing test. You say that you are entitled to a
free hearing test. You say you should not be responsible for the amount. The Plan denied your request. The
Plan says you have been asked to pay 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 $150
copayment for other outpatient diagnostic tests. For this date of service, you have been asked to pay the
allowed amount of the claim because this amount is less than the standard $150 copayment for the diagnostic
hearing test.
You have been asked to pay $134.44 copayment for the diagnostic hearing test. The diagnostic hearing test
falls within the "Outpatient hospital services" benefit category. The record shows a diagnosis of unspecified
sensorineural hearing loss which makes the hearing test diagnostic in nature.
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 diagnostic hearing test provided on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you do not understand why these
supplies are denied. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the infliximab injections (J1745 x 2), chemotherapy infusions (96413, 96415), and the Vitamin B-12 injection (J3420) provided on March 19, 2021.

You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.

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% of the Medicare approved amount of the total cost of Medicare Part B prescription drugs provided.

You have been asked to pay $525.67 ($2,628.36 x 20% coinsurance) for the Medicare Part B drugs provided. 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 adjust the coinsurance for the infliximab injections (J1745 x 2), chemotherapy infusions (96413, 96415), and the Vitamin B-12 injection (J3420) provided on March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a mastectomy bra.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 out-of-network for a mastectomy bra.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee is not on insulin.

The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is only covered for
enrollees treated on insulin.

There is no evidence of insulin use in the case file. Based on this information, we decided that Medicare rules
for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for continuous glucose monitors have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.