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

We decided that the Plan does not have to pre-approve a wig received on October 3, 2019.You asked the Plan to pre-approve the services. You say that this should be covered.The Plan denied your request. The Plan says neither Medicare nor your plan provides coverage for wigs.The Plan must follow Medicare rules. The rules say that for equipment to be covered,it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a wig received on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased by the enrollee on August 28, 2019 from an out-of-network provider.You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says they researched all systems and there was not a pre-authorization nor clinical criteria met. The Plan states they reviewed your call historyin which; there were no calls made to the plan (customer service) prior to purchasing the item, to request any information of benefits or cost share for DME. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. As the plan does cover wheelchairs as stated in your 2019 EOC; DME; the item is to be rented; you are not to acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan. If you had utilized the DME benefit, you would have only been responsible for a 15% coinsurance for Medicare-covered benefits. Per Medicare guidance; Medicare covers items like oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare for use in the home. Some items must be rented. In addition; per your 2019 EOC; As a member of our plan, you usually will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan. It is advantageous to call the customer service department or review the EOC prior to medical services or purchases and this is recommended in order for you to utilize the plan benefits. Therefore, the DME was purchased and not rented as your plan benefit states. The claims denied correctly according to your benefits in the 2019 EOC. You are responsible for the full cost of services received.Therefore, we decided that the Plan does not have to pay for the DME purchased by the enrollee on August 28, 2019 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forKnee and Spine Orthotics (L0180, L1832) provided September 30, 2019 by.You asked the Plan to pay forthe orthotics. You say that the items were medically necessary.The Plan denied your request. The Plan says the physician orders and delivery tickets did not meet Medicare requirements.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. The physician order was invalid and there was no itemized invoice or receipt provided.Therefore, we decided that the Plan does not have to pay forKnee and Spine Orthotics (L0180, L1832) provided September 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDevrom tablets.You asked the Plan to pre-approveDevrom. You say that the tablets will help with the odor your ostomy bag is giving out.The Plan denied your request. The Plan says Devrom tablets are not a covered benefit by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Devrom is an OTC item.Therefore, we decided that the Plan does not have to pre-approveDevrom tablets
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a life alert system.You asked the Plan to pre-approve a life alert system. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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-approve a life alert system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T).
You asked the Plan to pre-approve the minimally invasive lumbar decompression. You say that the enrollee has been radiologically confirmed, clinically symptomatic lumbar stenosis with confirmed neurogenic claudication and associated moderate to severe pain. You say that the enrollee's condition has progressed such that activities of daily living are limited due to intensity of discomfort. You say that mobility, specifically standing and walking tolerance, has declined steadily. You say that, given the fact that the enrollee has tried and failed previous conservative treatment inclusive of physical therapy, epidural injections and pharmacological management for at least 6 weeks in the past 6 months and defers surgery at this time, the MILD procedure is currently the best option. The Plan denied your request. The Plan says the clinical value of the procedure in dispute has not been conclusively proven.
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. Medicare rules say that posterior decompression of the lumbar spine (PILD) for lumbar spinal stenosis (LSS) may only be covered under the context of a clinical trial. The records do not show that the enrollee is involved in a clinical trial. Based on this information, we decided that Medicare rules for coverage of the minimally invasive lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T).
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve direct skilled nursing services of a registered nurse in home health or hospice setting.You asked the Plan to pre-approve the services. You say that the doctor said you cannot be alone.The Plan denied your request. The Plan says that there is insufficient clinical information to reference a specific clinical practice guideline, or policy to make a determination.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not provided MAXIMUS any medical records with which to base our determination. There is no evidence that he plan made an attempt to request these records.Therefore, we decided that the Plan has to pre-approve direct skilled nursing services of a registered nurse in home health or hospice setting.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/o rsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecardiology services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that you are not able to travel far because of your medical issues.The Plan denied your request. The Plan says your network has doctors who can do the services that are needed to treat your problem.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvecardiology services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal scaling and root planing -four or more teeth per quadrant (D4341) provided on December 2, 2019by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you do 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.The provider is not in-network and your EOC clearly states, the dental plan network allows you to go to any primary care dentist within the dentist network. You must use this dental network for your plan covered dental benefits.Therefore, we decided that the Plan does not have to pay forperiodontal scaling and root planing -four or more teeth per quadrant (D4341) provided on December 2, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network rheumatologist services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested out of
network provider. The Plan denied your request. The Plan says this service can be provided in 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 is not a network provider with the Plan. The Plan has network providers available who
can provide the services at issue in this appeal. We found no exception that would require the Plan to preapprove
these services. Therefore, we decided that the Plan does not have to pre-approve out of network
rheumatologist services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil tablets.You asked the Plan to pre-approve Modafinil. You say that this medication is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug 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 Modafinil tablets.Benefits for Modafinil 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea suction assisted lipectomy (CPT 15876) and rhytidectomy (CPT 15825).You asked the Plan to pre-approvethe procedures. The Plan denied your request. The Plan says cosmetic procedure are not covered.The Plan must follow Medicare rules. Medicare rules say that the services listed in A57743 are non-covered. We looked at the file and Medicare rules. The procedures are considered non-covered by Local Coverage Article A57743. Based on this information, we decided that Medicare rules for coverage of the procedures have not been met.Therefore, we decided that the Plan does not have to pre-approvea suction assisted lipectomy (CPT 15876) and rhytidectomy (CPT 15825).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on December 27, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this treatment is covered, but it can only be done one time.
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. You exhausted your benefit, because you had this service completed on November 27, 2019 and December 27, 2019. Your EOC clearly states, limited oral evaluation, problem focused (D0140) limited to once per patient per provider. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient psychiatric services rendered from December 12, 2019 to December 27, 2019.You asked the Plan to waive the copayment for these services. You say that you do not feel liable for the services.The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-5 for Medicare-covered stays at a psychiatric hospital. The file shows that you received inpatient psychiatric services from December 12, 2019 to December 27, 2019. You have been asked to pay a $300 copayment per day for days 1-5 for these services, for a total of $1,500. These services fall within the Medicare-covered stays at a psychiatric hospital benefit category. 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 forthe inpatient psychiatric services rendered from December 12, 2019 to December 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided ultrasound to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a guided ultrasound. You say that you would like approval for this service. You say that the member has exhausted all other options. The Plan denied your request. The Plan says there are in-network providers available for these services. 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 guided ultrasound to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7412, D9945, D9992, D9430).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says these 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. Therefore, we decided that the Plan does not have to pre-approve
dental services (D7412, D9945, D9992, D9430).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve manual wheelchair. You say that you have a ban knee and cannot walk, so you need this wheelchair. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the records do not show the results of a walking exam or that you are unable to use a cane or walker.
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered for enrollees that meet certain specific criteria. 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 manual wheelchair. Our reviewer says that you do not meet the Medicare criteria for the requested manual wheelchair. Our physician reviewer found there is no evidence that your mobility deficit interferes with your ability to perform mobility-related activities
of daily living in your home. There is no evidence that your mobility deficit cannot be resolved with an appropriately fitted walker or cane or that you will use the requested wheelchair on a regular basis in the home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI provided on October 17, 2019.You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 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 MRI.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 the MRI provided on October 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis.You asked the Plan to pre-approve the dental services. You say that you need the service before you can get bottom dentures started.The Plan denied your request. The Plan says the requested services are not covered under your benefit package.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.Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the removal of torus mandibularis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a routine eye exam provided on December 11, 2019.You asked the Plan to waive the copayment for a routine eye exam. You say that you should owe nothing for a routine eye exam.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for routine eye exams. You have been asked to pay a $15 copayment for a routine eye exam. A routine eye exam falls within the vision services benefit category. 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 a routine eye exam provided on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic radiology services (76700) provided on December 5, 2019.
You asked the Plan to waive the copayment for the diagnostic radiology services (76700). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an ultrasound, a diagnostic radiology service, on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.
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 $100 copayment for diagnostic radiology services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received an ultrasound on December 5, 2019. An ultrasound is considered a diagnostic test. You have been asked to pay a $100 copayment for the diagnostic radiology services (76700). The diagnostic radiology services (76700) fall within the Outpatient diagnostic tests benefit category. 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 radiology services (76700) provided on December 5, 2019.