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

We decided that the Plan does not have to pay for the eye exam provided on October 2, 2019.
You asked the Plan to pay for the eye exam. You say that you had this done because your doctor ordered it. The Plan denied your request. The Plan says that this denied correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says that they cover one routine eye exam (eye refraction exam) per calendar year. We looked at the file and the Plan's rules. The file indicates the plan covered an eye exam on April 9, 2019. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the observation care provided on June 4, 2018 through June 14, 2018. We decided that the Plan does not have to pay for observation care provided on May 26, 2018 through May 27, 2018.
You asked the Plan to pay for the observation care. You say that you would like reconsideration as this claim was filed timely. The Plan says that the claim was submitted after timely filing limitations.
We decided that the Plan has to pay for the observation care provided on June 4, 2018 through June 14, 2018.
The Plan follows Medicare rules. Medicare rules say that if a line item "From" date is not timely but the "To" date is timely, contractors must split the line item and deny the untimely services as not timely filed. The record indicates that the claim for dates of service June 4, 2018 through June 14, 2018 were filed timely. The claim was received by the Plan on May 29, 2019. Therefore, we decided that the Plan has to pay for the observation care provided on June 4, 2018 through June 14, 2018.
We also decided that the Plan does not have to pay for observation care provided on May 26, 2018 through May 27, 2018.
The Plan follows Medicare rules. Medicare rules say that claims for services furnished on or after January 1, 2010 must be filed no later than the close of the period ending 1 calendar year after the date of service. The record indicates that the claim for dates of service May 26, 2018 through May 27, 2018 was not filed timely. The claim was received by the Plan on May 29, 2019. Therefore, we decided that the Plan does not have to pay for observation care provided on May 26, 2018 through May 27, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the retainer crowns (D6750) for teeth # 24 and 26, and the pontic (D6242) for tooth # 25 provided on September 6, 2019.
You asked the Plan to reimburse you for the pontic. The Plan denied your request. The Plan says the pontic 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 pontic is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the retainer crowns (D6750) for teeth # 24 and 26, and the pontic (D6242) for tooth # 25 provided on September 6, 2019.
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 services are necessary. The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.
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 they are 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a primary closure of a sinus perforation (D7261 x 2), removal of lateral exostosis (D7471 x 2), a frenulectomy (D7960), and the therapeutic parenteral drug (D9610).
You asked the Plan to pre-approve 2 primary closure of a sinus perforation, removal of 2 lateral exostosis, a frenulectomy, and a therapeutic parenteral drug.. You say that you cannot afford to pay for the requested dental services. You also say that you need the requested dental services in order to get dentures. The Plan denied your request. The Plan says the requested dental services are not listed as 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a primary closure of a sinus perforation (D7261 x 2), removal of lateral exostosis (D7471 x 2), a frenulectomy (D7960), and the therapeutic parenteral drug (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zinger Chair from the facility.
You asked the Plan to pre-approve a Zinger Chair. You say that the enrollee cannot get a vehicle lift to transport the power operated scooter that was approved. The Plan denied your request. The Plan says the enrollee was approved for a power operated scooter but the Zinger Chair is not a medical device nor a wheelchair.
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. The Zinger Chair and the Zoomer chair are not designed to be medical equipment and therefore are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Zinger Chair from the facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits.
You asked the Plan to pre-approve the eight additional PT visits. You say that that you need eight additional PT
visits otherwise you will not be able to walk. The Plan denied your request. The Plan says the eight additional
PT visits are not medically necessary as you can continue to follow your home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the eight additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found for neck and back pain, physical therapy (PT) is
generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and
educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case,
there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function
and there is no indication residual deficits could not be addressed via a home exercise 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 the eight additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve eight additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are to help you with your foot sensitivity related to your neurological condition. You say that you believe the inserts would aid in improving your foot mechanics. 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 suffer from diabetic foot disease and 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, prophylaxis,
extraction, porcelain pontic, two first intraoral periapical x-rays, and porcelain crown provided on August 7,
2019 and August 14, 2019.
You asked the Plan to pay for the dental services. You say that you went to the only in-network provider
available where you live and were quoted over $5,000 of work to be done that you could not afford. You also
say that you went this provider who rendered the services because he gave you a price more in line with your
income and you assumed the Plan would give you some assistance. The Plan denied your request. The Plan
says services performed by an out-of-network provider are not covered because your healthcare plan does not
have out-of-network 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
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the problem focused limited oral evaluation, prophylaxis, extraction, porcelain pontic, two first intraoral
periapical x-rays, and porcelain crown provided on August 7, 2019 and August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide The Vest Airway Clearance System.
You asked the Plan to provide a high frequency chest wall oscillation device. You say that the enrollee needs a high frequency chest wall oscillation device because of chronic obstructive pulmonary disease. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to provide The Vest Airway Clearance System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and deep sedation/general anesthesia services provided on August 15, 2019.
You asked the Plan to pay for the extraction and deep sedation/general anesthesia services. You say that you spoke with a Plan representative who told you that if you used a dentist outside of the Plan's network and you paid the cost yourself the Plan would reimburse you for the amount allowed. You also say that you could not see a network dentist for several weeks and the tooth was extremely painful. The Plan denied your request. The Plan says this provider is not in-network. The Plan also says that non-emergency services provided by an out-of-network provider are not available within your dental 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the extraction and deep sedation/general anesthesia services provided on August 15, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis (74178). We decided that the
Plan does not have to pre-approve a CT scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis (74178) and a CT scan of the chest
(71250). You say that the requested CT scans are medically necessary. The Plan denied your request. The Plan
says that the requested CT scans are not medically necessary.
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis (74178).
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 a CT scan of the abdomen and pelvis
(74178). Our reviewer says that the requested CT scan of the abdomen and pelvis is medically necessary. Our
physician reviewer found the enrollee is status post liver transplant in 2015 for hepatocellular carcinoma
(HCC). A chest x-ray from 12/20/19 showed the enrollee's lungs were clear. A hepatology office note from
11/19/19 showed a respiratory review of the enrollee's systems was negative and heart and lungs exams were
normal. The enrollee had right lower extremity pain which had been evaluated by vascular surgery.
Patients are at risk for recurrence of HCC following liver transplantation. There is no consensus regarding the
optimal approach for post-transplant surveillance. Imaging every three to six months for two years, and then
annually has been suggested as a guideline by NCCN. The requested CT scan of the abdomen and pelvis is
medically reasonable and necessary in this case.
Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis (74178).
We also decided that the Plan does not have to pre-approve a CT scan of the chest (71250).
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 a CT scan of the chest (71250). Our
reviewer found that a chest x-ray completed on 12/20/19 demonstrated clear lungs. The documentation does
not support that a CT scan of the chest is medically reasonable and necessary for the enrollee in this case.
Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest (71250).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta.
You asked the Plan to pre-approve the Tradjenta. You say that The Plan denied your request. The Plan says the drug being requested is not covered under the enrollee's contract. The plan says that the enrollee does not have Part D prescription drug coverage through the plan.
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 Tradjenta.
Benefits for the Tradjenta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan extremity study.
You asked the Plan to pre-approve duplex scan. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan has already approved 2 studies during the year and additional testing is not necessary.
The Plan follows Medicare rules. Medicare rules say that duplex scan extremity studies are only covered for evaluation of certain condition, when considered medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve duplex scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested duplex scan. Our physician reviewer found the documentation does not support the medical necessity of this additional testing. There is no discussion on the results of the prior ablation procedure on the enrollee. There has been approval for additional varicose vein treatment procedures but no documentation that they were performed. There is no documentation that there has been a change in the enrollee's condition since the most recent study, therefore this additional study is not considered medically 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 duplex scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan extremity study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit fees for 36,000.00 pesos (99285) provided on October 5, 2018 through October 6, 2018.
You asked the Plan to pay for the emergency department visit fees. You say that you would like reconsideration as you paid for these services upfront to the provider. The Plan denied your request. The Plan says there was no itemized bill showing what the fees were.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Specifically, the documentation submitted does not include medical records or sufficient information to determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for emergency department visit fees for 36,000.00 pesos (99285) provided on October 5, 2018 through October 6, 2018.
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 the records provided support the need for SNF care. The Plan denied your request. The Plan says the guidelines for SNF coverage have not been met. The plan says that the enrollee can receive the care needed in another setting.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not indicate a need for skilled nursing services. The medical records do indicate a need for skilled therapy services, but they are not needed on a daily basis. The medical records do not indicate a need for inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate. 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 a maxillary partial denture (D5213).
You asked the Plan to pre-approve the dental item. You say that the material used in your current partial turned black. You say that it is lead. You also say that you do not want to keep using the dental partials because it may be bad for your health. The Plan denied your request. The Plan says the frequency limit has been reached. The Plan says that you last received partial dentures on May 16, 2019.
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 frequency limit has been reached for the partial denture. The record shows you last received partial dentures on May 16, 2019. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).