Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone.
You asked the Plan to pre-approve Oxycodone. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Oxycodone.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on December 16, 2019 from an out-of-
network provider.
You asked the Plan to pay for the eyewear. You say that you are entitled to one pair of eyeglasses under your
plan. The Plan denied your request. The Plan says the services are not covered.
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.
We looked at the file and the Plan's rules. The Plan will only cover eyewear for enrollees following a cataract
surgery. Your request for reimbursement did not indicate that the eyewear you purchased on December 26,
2019 was intended to assist in recovery from cataract surgery. You do not have coverage for supplemental
eyewear. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on December 16,
2019 from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on January 21, 2020. You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit. 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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no medical records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture.
You asked the Plan to pre-approve the denture. You say that this is not medically necessary. The Plan denied your request. The Plan says the Plan got terminated on March 31, 2020.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. You no longer have a supplemental benefit for dental services. Therefore, we decided that the Plan does not have to pre-approve a complete denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthoses, heel stabilizers, knee orthosis and sleeve provided to the enrollee on August 19, 2019.
You asked the Plan to pay for these items. The Plan denied your request. The Plan says that review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle/foot orthoses, heel stabilizers, knee orthosis and sleeve provided to the enrollee on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown for tooth #8 and #9.
You asked the Plan to pre-approve the crowns. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental crown for tooth #8 and #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures and a dental implant.
You asked the Plan to pre-approve dentures and a dental implant. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 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. 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 dentures and a dental implant.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TEE).
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 enrollee has hypertension and an unspecified heart murmur. An office report dated February 4, 2020 reports no murmur on exam. There is no report of a previous TEE for review. The submitted records do not support that the TEE is reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TEE).
Local Coverage Determination (LCD) L33579 referenced by the Plan is for the wrong jurisdiction and was not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services.
You asked the Plan to pre-approve the services. You say that you receive a small social security check, and you
are not able to afford implants. The Plan denied your request. The Plan says you have fully exhausted your
$100 quarterly comprehensive dental allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the services
when the services are medically necessary and reasonable.
You fully exhausted your dental allowance with procedure code D6010 on March 12, 2020. Based on this
information, we decided that the Plan's rules for coverage of additional the services for this quarter have not
been met. Therefore, we decided that the Plan does not have to pre-approve dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.You asked the Plan to pre-approve the lift. You say that this is medically necessary.The Plan denied your request. The Plan says this 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 stair lift.
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 these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not have a condition for which the services are covered.
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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 21,
2020.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit
and you disagree with the charges. 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 $10
copayment for primary care provider visits.
The medical records show that you received services beyond an annual wellness visit on January 21, 2020.
Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits 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 office visit provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoes.You asked the Plan to pre-approve these services. You say that your left foot is severely deformed.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. The file shows that the orthotics are being requested for limb length discrepancy. 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 custom shoes.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox 100 unit injection (J0585).
You asked the Plan to pre-approve Botox 100 unit injection. You say that the requested medication is necessary since this is the only procedure that has worked for your condition. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that botulinum toxin products may be covered when deemed 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 Botox 100 unit injection. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Botox injections are medically reasonable and necessary for you. The Local Coverage Determination (LCD): Botulinum Toxin Type A & Type B (L34635) and the Medicare-approved compendia do not support use of Botox injections for diabetic gastroparesis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox 100 unit injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox 100 unit injection (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered, as it is 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 a power seat elevation system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you would prefer to see this doctor
because he can provide one surgery that lasts a lifetime. The Plan denied your request. The Plan says there are
in-network providers available to provide 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 specialist office visit 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 a shower chair. You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because you are unable to get to the shower without a bench. The Plan denied your request. The Plan says Durable Medical Equipment items that do not primarily serve a medical purpose and which are not reasonable and necessary to treat an illness or injury are not covered under any condition. The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20610, J7327, 99212) provided on October 10,
2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 20610 is "Arthrocentesis, aspiration and/or injection,
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance". The CPT Code
Manual Definition of code J7327 is "Hyaluronan or derivative, monovisc, for intra-articular injection, per
dose".
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 services. Our reviewer says that the use
of code 20610 and J7327 is not supported by the records provided. Our physician reviewer found that the
medical records provided do not include documentation to validate that a bilateral, Arthrocentesis, aspiration
and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
was performed on October 10, 2019, therefore CPT 20610 cannot be verified. The medical records provided
does not support 2 units of Hyaluronan or derivative, monovisc; for intra-articular injection, per dose, therefore
J7327 cannot be verified.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 20610 and J7327 have not been met.
Medicare rules also say that the Medicare approved amount for global surgery procedures includes payment for
the above services related to the surgery when furnished by the physician who performs the surgery.
The visit in question (CPT 99212) was provided to the enrollee on the same date of service as the surgical
procedure. The surgical procedure in question has a global day indicator of 000. Services related to the surgery,
and provided on the same date as the surgery, are included in payment for the surgical procedure and are not
separately payable. Therefore, we decided that the Plan does not have to pay for the services (20610, J7327,
99212) provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calcium 1000 mg and Vitamin D3 with Magnesium, Glucosamine extra strength 2000 mg, Chrondroitin 1200 mg MSM Vitamin D3, Children's Chewable Complete Multivitamin Dietary and Prevident Rinse 0.2% Solution.
You asked the Plan to pre-approve the over-the-counter items. You say that you selected this plan because it had over-the-counter benefits and you feel that these products should be included due to your medical and nutritional needs. The Plan denied your request. The Plan says these items are not included in the over-the-counter catalog and is therefore not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the plan has an over-the-counter benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The over-the-counter benefit is limited to drugs or items as specified by the plan. The items are not listed in the plan's over the counter catalog. Therefore, we decided that the Plan does not have to pre-approve Calcium 1000 mg and Vitamin D3 with Magnesium, Glucosamine extra strength 2000 mg, Chrondroitin 1200 mg MSM Vitamin D3, Children's Chewable Complete Multivitamin Dietary and Prevident Rinse 0.2% Solution.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an dental occlusal device.
You asked the Plan to pre-approve the occlusal device. You say that the services are necessary. The Plan
denied your request. The Plan says this is not 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. The plan covers only those dental services listed in the Evidence of Coverage.
Dental occlusal devices are not covered. Therefore, we decided that the Plan does not have to pre-approve an
dental occlusal device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested cystoscopy.
You asked the Plan to pre-approve the cystoscopy. You say that were approved for a second opinion by your
Medical Group and have seen this provider who has requested that you return for a cystoscopy and discussion
of treatment options. The Plan denied your request. The Plan says this provider specializes in cancer and the
second opinion did not suggest that you have prostate cancer. Therefore, your care can be continued with a
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 contract with
the Plan also says that the plan requires you to receive care from providers who are part of your primary care
physician's (PCP) specialty network.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the cystoscopy. 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-approve the requested cystoscopy.