Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 26, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services require prior authorization.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reline of a complete upper denture (D5730).
You asked the Plan to pre-approve the dental service. You say that this is the same provider that did your dentures 2 years ago. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services received out of network 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 dental service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a reline of a complete upper denture (D5730).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 15, 2019.
You asked the Plan to pay for the dental service. You say that you broke a crown. You also say that the second evaluation was necessary to determine treatment. The Plan denied your request. The Plan says the frequency limit has been exceeded.
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 for the limited oral evaluation has been exceeded. The record shows that the Plan previously paid for an oral evaluation on May 13, 2019. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on September 6, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you didn't expect the copayment to be that high. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $250 copayment for outpatient diagnostic tests/diagnostic radiology provider's office. You have been asked to pay a $250 copayment for an MRI. An MRI falls within the outpatient diagnostic tests/diagnostic radiology provider's office 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 an MRI provided on September 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve the physical therapy visits. You say that you would like reconsideration as the additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for additional physical therapy visits.
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 physical therapy 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 there is no indication that prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there is no indication that residual deficits could not be addressed with 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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute is not medically necessary. The item at issue is a crutch substitute described by code E0118. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Emgality for the enrollee.
Benefits for these services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 4, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transports.
You asked the Plan to approve these services. You say that you need transportation to dialysis. The Plan denied your request. The Plan says you have exhausted the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 18 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that you have used 10 of the 18 total one-way transports allowed by your supplemental benefit. Once you have used all 18 one-way trips, further trips are not covered by Medicare or your supplemental benefit. Therefore, we decided that the Plan does not have to approve additional routine transports.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy with dental code D3348.
You asked the Plan to pre-approve retreatment of previous root canal. You say that you are appealing because this procedure is an emergency and you cannot afford to pay for this. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because retreatment of previous root canal therapy with dental code D3348 is not covered by Medicare or 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 retreatment of previous root canal therapy with dental code D3348.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the transurethral resection surgery provided on March 11, 2019.
You asked the Plan to reduce the copayment for the transurethral resection surgery. You say that you should be charged the $100 copayment because the surgery was performed at an ambulatory surgery center. 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 $200 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $200 copayment for the transurethral resection surgery. The transurethral resection surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you had this surgery at an outpatient hospital.
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 reduce the copayment for the transurethral resection surgery provided on March 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on September 9, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you are on a very limited income and covering this expense creates a hardship for you. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. The Plan also says that this provider is out-of-network.
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, exams are limited to two procedure per plan year. The record shows that you received limited oral evaluations on May 15, 2019 and May 28, 2019 and your exams benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exceptions for Fasenra 30mg/ml syringe.
You asked the Plan to pre-approve the services. You say that coverage should be reconsidered. The Plan denied your request. The Plan says tier exceptions are not covered by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. 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 a tier exceptions for Fasenra 30mg/ml syringe.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted documentation provides the possibility of a dumping syndrome with relatively rapid gastric emptying. There appears to be little clinical significance to the "narrowed pylorus" identified six months ago. Certainly gastric emptying scan has ruled out gastroparesis. The medical appropriateness and necessity of intrapyloric botox injection and pyloric dilation is not apparent from available records, and may be contraindicated if the enrollee indeed has a dumping syndrome in her setting of diabetes. Botox is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for orthovisc for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says Part B drugs are not eligible for a tier exception.
The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A or Part B to the individual for such drug, then it will not be covered under Part D. The services at issue are orthovisc. This is a Part B drug and is therefore not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for orthovisc for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that the MRI of the cervical spine is needed for further detailed information for symptoms of nerve compression, for evidence of instability on the x-ray, and for evaluation of the spinal cord for reactive changes. The appellant says that the requested MRI is necessary to appropriately treat the enrollee. The Plan denied your request. The Plan says the records provided do not show that the criteria for coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the documentation provided does not support the medical necessity of the requested MRI. Our physician reviewer found the enrollee was evaluated on December 23, 2019 and was reporting pain in the neck, shoulders, and arms. The provider noted pain in the paraspinal area, as well as a decreased range of motion with intact strength and sensation. The assessment outlines a diagnosis of radiculopathy of the cervical region with a plan for cervical MRI. There is no documentation of attempted treatment modalities or a differential diagnosis. The enrollee did undergo cervical spine plain films on January 13, 2020 for reported non-traumatic chronic neck stiffness. Follow-up assessment by the provider was not included for review. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210), and the periodontal maintenance (D4910) provided on October 3, 2019.
You asked the Plan to pay for the x-rays and periodontal maintenance. You say that the $500 maximum benefit can be adjusted to a higher amount because you suffer from gum disease, according to the 2019 Plan Benefits description. The Plan denied your request. The Plan says the maximum benefit of $500 has been exceeded.
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, the maximum benefit has been exceeded. The record shows that the Plan previously paid $250 for services you received on January 25, 2019, $200 for services you received on June 3, 3019, and $50 towards the services that you received on October 3, 2019. Therefore, we decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210), and the periodontal maintenance (D4910) provided on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three extractions provided on July 31, 2019.
You asked the Plan to pay for the three additional extractions. You say that you called the Plan before you found a dentist to provide the extractions. You also say that 6 months later another tooth broke and this provider treated you like a human being. 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.
The contract clearly states that extractions are limited to one procedure per calendar year and you are required to pay the full cost when the services are received out-of-network. The record also shows that the plan paid for one extraction at the in-network rate. Therefore, we decided that the Plan does not have to pay for the three extractions provided on July 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve spinal surgery. You say that there is no one in your area that can do this procedure, and you have already booked a hotel and airline tickets. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertebroplasty/kyphoplasty for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 requested procedure is considered experimental at multiple levels in the lumbar spine. Recent literature supports that it is not effective. The surgery is not reasonable or medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a vertebroplasty/kyphoplasty for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Stretta procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is not reasonable or necessary for the treatment of GERD, as there is insufficient data to prove long-term effectiveness.
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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found Stretta was approved by the United States Food and Drug Administration (FDA) in 2000. This endoscopic technology was originally produced and marketed by a company that filed for bankruptcy in 2006. The device has been the subject of recalls as well as observational studies aimed at re-assessing device safety and efficacy. The use of the Stretta procedure must be approached with caution given the enrollee's dysmotility-associated dysphagia, which relatively contraindicate to the service under review. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Stretta procedure for the enrollee.