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

We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedure, per first tooth, implant or endentulous tooth position in graft on teeth #25, #27, #31 and #21.
You asked the Plan to pre-approve these services. You say that this was covered previously. The Plan denied your request. The Plan says that this is not covered under your contract.
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 autogenous connective tissue graft procedure, per first tooth, implant or endentulous tooth position in graft on teeth #25, #27, #31 and #21.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the custom-fitted mandibular sleep apnea appliance provided on August 5, 2019.
You asked the Plan to pay for the oral sleep appliance. You say that you have sleep apnea and could not tolerate a breathing machine. The Plan denied your request. The Plan says that there was a lack in documentation of AHI and failure of prior therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the oral sleep appliance. Our reviewer says that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found in this instance, the enrollee had presented for polysomnography on October 15, 2018 at the direction of
the provider and had a determination of an AHI of 19.7. On August 5, 2019 the enrollee presented for delivery of a custom made sleep apnea device supplied by the provider. Criteria is met for AHI ranges as it is 19.7. The criteria that a referral for a sleep appliance be made following the report of the sleep study appears to be met as the provider had ordered the original study. The narrative provided by the enrollee indicated the enrollee was referred after failure of CPAP to the provider for an appliance, noting that there are no clinical records available to support this. The criteria that the device was provided and billed by a licensed dentist appears to be met. Following the sequence of events from the enrollee's narrative in conjunction with the available records and noted time frames it would appear that the enrollee did have a physician requested sleep study with attempted and failed CPAP treatment and then referral to a dentist for an oral appliance. Given the totality of the record available it appears that all the criteria for the sleep appliance has been met. 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 oral sleep appliance have been met. Therefore, we decided that the Plan has to pay for the custom-fitted mandibular sleep apnea appliance provided on August 5, 2019.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveesophagogastroduodenoscopy (EGD) with delivery of thermal energy to the muscles (Stretta procedure).You asked the Plan to pre-approveStretta procedure. You say that you feel that this is the best option for you.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this procedure is considered experimental/investigational.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Stretta procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in the case of this enrollee with severe conditions, she had taken proton pump inhibitors (PPIs) for almost 30 years and now has osteoporosis. Continues daily use of this medication would likely worsen her osteoporosis. Evenwith PPI use, she has incomplete resolution of her symptoms. The enrollee is a candidate for the Stretta procedure over a fundoplication. Although for certain patients fundoplication may provide effectiveness marginally more than the Stretta procedure, there is a more significant rate of side effects and risks associated with fundoplication, including dysphagia and mortality. A recent analysis of studies evaluating the Stretta procedure concluded that there was a significant improvement in quality of life with patients able to get off of PPIs. The goal of this enrollee is to not be dependent on her PPIs, yes have resolution or reduction in symptoms with the least amount of risk. Sufficient data has been gathered for this procedure to not be considered experimental or investigational. Based on this information, Medicare coverage criteria has been fulfilled and this procedure is 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 Stretta procedure have been met.Therefore, we decided that the Plan has to pre-approveesophagogastroduodenoscopy (EGD) with delivery of thermal energy to the muscles (Stretta procedure).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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 23, 2019 to July 22, 2019.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says skilled services were not needed after June 22, 2019.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found for the dates of service in question, the enrollee did not have any identifiable skilled nursing or therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 23, 2019 to July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment supported crown (D6059) for tooth # 31.
You asked the Plan to pre-approve the dental services. You say that the services were recommended by your dentist. You say that your dentist advised the services were necessary. You also say that the services should be covered based on your Dental Rider Supplemental Benefit. The Plan denied your request. The Plan says custom fabricated abutments are not a covered service. The Plan also says abutment supported crowns are not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 custom fabricated abutment (D6057) and an abutment supported crown (D6059) for tooth # 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone graft in conjunction with periradicular surgery (D3429).
You asked the Plan to pre-approve the dental services. You say that your dentist has recommended 3 extractions and the bone graft for all three in order to do implants that are medically necessary so that you can eat. The Plan denied your request. The Plan says this service is not listed as a covered benefit.
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. Procedures not listed on the benefits chart is not covered by the plan. 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 bone graft in conjunction with periradicular surgery (D3429).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for all 4 quadrants, and periodontal maintenance (D4910).
You asked the Plan to pre-approve the dental services. You say that the enrollee desperately needs scaling and root planing. The Plan denied your request. The Plan says periodontal scaling and root planing, and periodontal maintenance are not covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for all 4 quadrants, and periodontal maintenance (D4910).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the service requested 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 an enrollee must be between 55 and 77 years old for LDCT Lung Cancer Screenings to be covered. We looked at the file and Medicare rules. The record shows the enrollee is 53 years old. Coverage criteria isn't met in this case. Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening. have not been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on November 25, 2019 through November 30, 2019.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider does not have a valid Medicare CMS Certification Number and is not PPS expempt.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, the record indicates that this provider is not enrolled in the Medicare program and is not PPS exempt. Therefore, we decided that the Plan does not have to pay for outpatient services provided on November 25, 2019 through November 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 prefabricated post and core in addition to a crown (D2954) and 9 crowns (D2751).
You asked the Plan to pre-approve the dental services. You say that you have a lot of mouth pain. You say that you had to be on antibiotics due to infections. You say that the teeth are causing you pain in your ear and neck. You also say that you feel that you need this dental work completed as soon as possible. The Plan denied your request. The Plan says prefabricated post and core in addition to a crown and crowns are not covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested prefabricated post and core in addition to a crown and crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 16 prefabricated post and core in addition to a crown (D2954) and 9 crowns (D2751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that you would like a new wheelchair. The Plan denied your request. The Plan says that you received a new power wheelchair in 2018.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. You received a power wheelchair on March 8, 2018, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services you received from August 22, 2019, to August 24, 2019.
You asked the Plan to waive the coinsurance. You say that you were in the hospital and should not be responsible for the bills. The Plan denied your request. The Plan says you are responsible for the cost share.
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 20% coinsurance for each surgical or observation room service you get at an outpatient hospital. Review of the file shows that you were provided outpatient observation care from August 22, 2019, to August 24, 2019. You have been asked to pay a 20% coinsurance for the services, totaling $54.44. The services fall within the outpatient hospital 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 coinsurance for the outpatient hospital services you received from August 22, 2019, to August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair options.
You asked the Plan to pre-approve power wheelchair LED light kit, armrest pouch, USB charger, and power seat elevation feature. You say that the power wheelchair was ordered in good faith understanding the options were approved. The Plan denied your request. The Plan says the options are primarily convenience and not medically necessary to participate in mobility related activities of daily living or necessary for the function of the wheelchair.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The options at issue in this appeal do not serve a purpose that is primarily medical in nature. The items are 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 the power wheelchair options.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve urology services. You say that you have made multiple in-network office visits. You say that multiple in-network providers have told you they cannot do the type of surgery you need. The Plan denied your request. The Plan says you have been approved to see another Medical Group.
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 urology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SoClean CPAP sanitizing machine (E1399) and reclining bathtub chair (E1399).
You asked the Plan to pre-approve the SoClean CPAP sanitizing machine and reclining bathtub chair. You say that you have difficulty getting in and out of the tub and you require a CPAP for management of your sleep apnea and require the SoClean device to help keep the breathing machine clean. The Plan denied your request. The Plan says These items are not covered. Medicare does not cover routine cleaning equipment nor hygienic equipment as it is not primarily medical in nature.
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 SoClean CPAP sanitizing machine (E1399) and reclining bathtub chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve varicose vein treatment. You say that this was a continuation of care. You say that you would like approval for these services. The Plan denied your request. The Plan says these services can be provided by an in-network provider. The Plan says that you have been approved to see two in-network providers.
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. Please contact the Plan for the names of in-network providers available for these services. 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 varicose vein treatment 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 a crown (D2740) for tooth #13 and mandibular partial denture (D5212).
You asked the Plan to pre-approve the crown for tooth #13 and mandibular partial denture. The Plan denied your request. The Plan says these services exceed the benefit allowances.
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, crowns are limited to once per tooth per 60 months, and mandibular dentures are limited to once per 60 months. The record shows that you received a crown (D2740) on tooth #13 on March 5, 2018, and you received a mandibular partial denture (D5212) on January 27, 2016, and your crowns benefit for tooth #13 and mandibular dentures benefit are now exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #13 and mandibular partial denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP kit and adapter (99070).
You asked the Plan to pre-approve  CPAP kit and adapter. You say that this item is medically necessary as it reduces infection and promotes compliance to prevent cardiac remodeling in this severe yet preventable chronic disease. The Plan denied your request. The Plan says this item is considered a convenience item and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public 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 CPAP kit and adapter (99070).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eye procedure (0402T)
You asked the Plan to pre-approve the eye procedure. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that A56195 provides a list of services that are considered not medically necessary. We looked at the file and Medicare rules. Per A56195, the requested eye procedure, represented by code 0402T, is not medically necessary. Based on this information, we decided that Medicare rules for coverage of the eye procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an eye procedure (0402T)