Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16).
You asked the Plan to pre-approve the remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16). You say that the remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16) are medically necessary. The Plan denied your request. The Plan says the remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16) 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 the remaining tube feeding and supplies
(B4150 x 1860, B4034 x 124, and B9998 x 16). Our reviewer says that the remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16) are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a gastrostomy feeding tube. The record does not provide sufficient information why the enrollee requires six month supplies rather than two months' supply as approved by the plan. The requested service is not medically necessary and reasonable, as defined by Medicare rules, for the enrollee's condition. The elements of the coverage rules are not satisfied. The requested service is not recommended. 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 remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16) have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining tube feeding and supplies (B4150 x 1860, B4034 x 124, and B9998 x 16).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 17, 2020, to August 19, 2020.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this bill. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment per day for days 1-7 for inpatient hospital care. 

Records show that you were in the hospital for two days. You have been asked to pay a $250 copayment per day for this stay, for a total of $500. 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 inpatient hospital services you received from August 17, 2020, to August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6104).

You asked the Plan to pre-approve the services. 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 dental services (D6104).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be rendered by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for durable medical equipment purchased on March 16, 2021.

You asked the Plan to pay for this equipment. You say that this was an emergency and you needed this equipment quickly. The Plan denied your request. The Plan says neither Medicare nor the Plan will pay for equipment purchased from a provider who is not eligible to accept Medicare payment.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a vendor who is not a Medicare eligible provider. This equipment was purchased from a vendor who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for durable medical equipment purchased on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 4.
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the handling fee for a power wheelchair.
You asked the Plan to pre-approve the fee. You say that you disagree with this denial. The Plan denied your request. The Plan says this is included in the charges for the power wheelchair.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The handling fee is not a medical item. The fee is included in the charges for the power wheelchair itself. Therefore, we decided that the Plan does not have to pre-approve the handling fee for a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on May 3, 2021.
You asked the Plan to waive the copayment for an EGD. You say that you should not owe a copayment for colorectal cancer screenings. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on May 3, 2021. EGD's are considered diagnostic outpatient surgical procedures and are
not included in colorectal cancer screenings. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on May 6, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says with limited
exceptions, while the enrollee is a member of our plan the enrollee must use network providers to get medical
care and services. The only exceptions are emergencies, urgently needed services when the network is not
available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes use of out-of-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 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
hearing aids. We found no exception that would require the Plan pay for these services. Therefore, we decided
that the Plan does not have to pay for hearing aids provided on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on July 21, 2020.
You asked the Plan to pay for out of network hearing aids. You say that you believe the Plan should cover
these hearing aids. The Plan denied your request. The Plan says hearing aids purchased from a non-Plan
provider are not covered. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays
for hearing aids purchased from a Plan provider. You did not choose a Plan provider. Therefore, we decided
that the Plan does not have to pay for hearing aids purchased on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan of the heart with absolute quantitation of myocardial blood flow.
You asked the Plan to pre-approve the cardiac FDG PET scan. You say that you feel that this testing is needed to help determine the necessary treatment to prevent heart issues. The Plan denied your request. The Plan says there were no inconclusive findings on the SPECT you have already had. No further imaging is needed as the diagnosis is complete.
The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 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 cardiac FDG PET scan. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee had a recent SPECT test that showed mild ischemia (reduced/inadequate blood flow) of the anterior wall and moderate ischemia of the inferior wall and inferior apex. The record does not indicate that the enrollee is undergoing revascularization. The SPECT test was not inconclusive. The elements of the coverage criteria are not satisfied.
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 cardiac FDG PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan of the heart with absolute quantitation of myocardial blood flow.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 15, 2019 to December 16, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says the acute inpatient hospital admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on December 14, 2019, with complaints of bilateral leg numbness for eighteen months and hip pain after two falls. He informed the ED that he was recently released after a forty day stay due to bacteria in his stool, urine and dysuria. His urine was positive for Opiates and Benzodiazepine. The urinalysis was negative for ketones, blood, protein, nitrates, leukocytes and bilirubin. The x-ray of the hip, femur, and pelvis bilaterally were negative and the computed tomography scan of the head (CTH) indicated no evidence of acute intercranial injury, generalized parenchymal. The member was given Librium in the ED to prevent withdrawal. He was then admitted on December 15, 2019 for evaluation of falls, inability to safely ambulate and to receive physical and occupational therapy services. On December 16, 2019, the member eloped from the hospital, noted with steady gait, in no acute distress and in full capacity.The enrollee did not receive any acute services during his admission. The review has determined that record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided December 15, 2019 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64493, 64494).
You asked the Plan to pay for facet joint injections. You say that you need pain relief. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that facet joint procedures are considered medically reasonable and necessary if the patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used. We looked at the file and Medicare rules. The submitted medical records do not show that you have had two diagnostic procedures with at least 80% pain relief. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64493, 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
You asked the Plan to pre-approve the inpatient psychiatric admission. You say that it is felt that inpatient admission is needed. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric admission. Our reviewer says that the requested admission to inpatient status is not considered medically reasonable and necessary. Our physician reviewer found this 49-year-old male was admitted to the acute inpatient psychiatric hospitalization on August 19, 2021 with Bipolar Disorder Current Episode Manic without Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The patient was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 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 inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2).
You asked the Plan to pre-approve the crowns and core buildups. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit 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 two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7230) and removal of a benign odontogenic cyst or tumor (D7450).
You asked the Plan to pre-approve the extractions. You say that the requested services are medically necessary. You say that the enrollee has been experiencing periodic pain and swelling off and on for about 2 years. You also say that The Plan denied your request. The Plan says removal of an impacted tooth is not listed as a covered service. The Plan also says that removal of a benign odontogenic cyst or tumor is not listed as a covered service either.
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 removal of an impacted tooth and removal of a benign odontogenic cyst or tumor are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of an impacted tooth (D7230) and removal of a benign odontogenic cyst or tumor (D7450).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve a second opinion. You say that you would like approval for a second
opinion to be provided by an out-of-network. 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 second opinion 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 second opinion to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be rendered by the out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of benign nonodontogenic cyst or tumor, greater than 1.2 cm (D7461), and removal of benign nonodontogenic cyst or tumor, up to 1.25 cm (D7460).
You asked the Plan to pre-approve the dental services. You say that you need a biopsy. You say that this is an emergency procedure. You also say that it should be covered. The Plan denied your request. The Plan says the requested services are not listed as 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of
benign nonodontogenic cyst or tumor, greater than 1.2 cm (D7461), and removal of benign nonodontogenic cyst or tumor, up to 1.25 cm (D7460).