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

We decided that the Plan does not have to pre-approvea crown (D2740) for tooth # 19.You asked the Plan to pre-approvethe dental services. You say that the enrollee has large amalgam fillings with recurrent decay on teeth # 18 and 20. You say that tooth # 19 has recurrent decay under a previous crown that was received before they were first seen in your office in 2009. You say build up will be needed for each tooth due to over 70% of the tooth structure will be compromised after decay and amalgam filling is removed. You also say that build up is needed to stabilize the tooth structure.The Plan denied your request. The Plan says crowns for teeth # 18 and 20 are not medically necessary at this time. The Plan also says teeth # 18 and 20 do not have significant breakdown.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 dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the request crowns for teeth #18 and 20 are not medically necessary. Our physician reviewer found the x-ray of tooth # 20 does not clearly show decay on the distal surface though there is a radiographic artifact seen. The existing restoration appears to be a standard two surface amalgam of moderate size. Tooth # 18 does not have clear area of decay on the mesial where the arrow has been superimposed. Therefore, the reviewer found that the requested crowns are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown (D2740) for tooth # 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional chiropractic visits (98941).You asked the Plan to pre-approvethe additional visits. You say that you are requesting continuation of care related to your condition which the records show that your condition is improving.The Plan denied your request. The Plan says the plan approved 4 of the requested 8 visits. Care is rarely authorized for more than a 1-month time frame. More care is approved when the records show that you are improving.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 additional visits Our reviewer says that this enrollee does not meet the criteria for additional visits. Our physician reviewer found there are no submitted imaging studies to reveal evidence of a subluxation and the submitted chiropractic treatment plan reveals that the enrollee is improving in range of motion of the neck and the low back also improved, since her onset. In addition, there is no evidence of an injury or trauma. Despite stated weekly visits, there is no evidence of any chiropractic chart notes. Medical necessity of the additional chiropractic treatments is not established and is not supported per Medicare guidelines.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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve4 additional chiropractic visits (98941).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 surgical extractions (D7210) and a consultation including oral evaluation (D9310) with an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that the services that you require cannot be performed by a general dentist. You say that you need to see an oral surgeon because your broken teeth need to be cut out. You say that you have been on antibiotics for 30 days to keep the infection down. You also say that you survived prostate cancer, have diabetes, high blood pressure and high cholesterol.The Plan denied your request. The Plan says dental services must be performed by a participating general dentist in order to be covered. The Plan also says that dental services performed by an oral surgeon 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, dental services must be performed by a participating general dentist in order to be covered. Dental services performed by an oral surgeon are not covered.Therefore, we decided that the Plan does not have to pre-approve2 surgical extractions (D7210) and a consultation including oral evaluation (D9310) with an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the enrollee would benefit from custom orthotics due to her leg length discrepancy contributing to low back pain and hip pain bilaterally.The Plan denied your request. The Plan saysthatthese orthotics are not part of an integral brace.The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The Plan follows these same rules.We looked at the file and Medicare rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Based on this information, we decided that Medicare rules for coverage of foot orthotics have not been met.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEpogen for the enrollee.You asked the Plan to pre-approveEpogen. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee has not met step therapy requirements.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Epogen. Our reviewer says that Epogen is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Retacrit (Epoetin alfa-epbx) or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Epogen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met.Therefore, we decided that the Plan does not have topre-approveEpogen for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on May 16, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on May 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99204), the preparation of an oral appliance (21089), the full mouth x-ray of teeth (70320), and the x-ray exam of jaw joints (70330) provided from November 4, 2019 to November 13, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that you needed an EMA oral appliance to help with your snoring issues. You say that this is a medical issue because it helps to keep your jaw in a position that keeps my tongue from closing off my airway which then causes snoring. You say that this appliance takes the place of a CPAP machine that can also be used to treat extreme snoring. You also say that the services you received on November 4, 2019 and November 6, 2019 should be covered as medical as well.The Plan denied your request. The Plan says authorization was not obtained before you received the 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit (99204), the preparation of an oral appliance (21089), the full mouth x-ray of teeth (70320), and the x-ray exam of jaw joints (70330) provided from November 4, 2019 to November 13, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra eye drops for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this is not covered under Part B.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-approveXiidra eye drops for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora FreeStyle Libre Continuous Glucose Monitoring (CGM) system.You asked the Plan to pay fora CGM. You say that you want a CGM.The Plan denied your request. The Plan says criteria for a CGM is not met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The record shows you are not insulin treated three or more times a day and there is no log oftesting four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pay fora FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedentistry services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvedentistry services. You say that her care is particularly necessary due to your severe claustrophobia.The Plan denied your request. The Plan says you have been approved to seein network doctors.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-approvedentistry services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation and four extractionsto be provided by an oral surgeon.You asked the Plan to pre-approvethe consultation and extractions. You say that you need this work done and were under the impression that Medicare covered work done by oral surgeons.The Plandenied your request. The Plan says dental services by an oral surgeon are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are only covered when they are received by a participating provider.Therefore, we decided that the Plan does not have to pre-approvea consultation and four extractions to be provided by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 31, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 80307 and HCPCS G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services provided to the enrollee on March 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical items to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve Continuous Positive Airway Pressure (CPAP) device and humidifier. You say that you were told by a plan representative to use this provider, so they should be considered in-network. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this provider is out-of-network with the Plan and these items can be obtained from an in-network supplier such as Rezk Medical Supply, MedCare Equipment, Vantage Home Medical, or One Click Health.
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 items 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-approveeyeglassframes and lenses.You asked the Plan to pre-approvethe vision services. You say that you are a diabetic and you had  recent eye exam which showed your eyes are really bad. You would like access to the frames and lenses benefit so that you will be able to see.The Plan denied your request. The Plan says the enrollee is eligible for 1 routine eye exam but is not eligible for the $300 allowance for the eyewear benefits.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. The Plan covers these services when the eyewear benefit is covered 1 time every 2 years and 1 routine eye exam every year. The records show that the eyewear benefit was used on January 28, 2019 and therefore will not be eligible for coverage until January 1, 2021.  We looked at the file and the Plan's rules. The eyewear benefit is covered 1 time every 2 years and 1 routine eye exam is covered every year. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pre-approveeyeglass frames and lenses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cleaning (D1110) provided on November 12, 2019.You asked the Plan to pay forthe cleaning (D1110). You say that you were told you had two cleanings per year. You say you later found out you only have one cleaning per year. The Plan denied your request. The Plan says the benefit limitation is exhausted.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, there is a benefit limit for the cleaning (D1110). The plan clearly states that only one cleaning procedure is covered per year. The records show the Plan paid for one cleaning on May 7, 2019 which exhausted the benefit. Therefore, we decided that the Plan does not have to pay forthe cleaning (D1110) provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on September 3, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says auto insurances coverages are responsible for payment before the health plan pays for the services.The Plan must follow Medicare rules. Medicare rules say that Medicare may not pay for items and services for which payment has been made or can reasonably be expected to be made promptly under anautomobile insurance plan. We looked at the file and Medicare rules.The services in question were provided as a result of an automobile accident. Payment cannot be made for services for which payment can reasonably be expected to be made by an automobile insurer.The claim must first be filed with, and denied by the automobile insurer before payment can be considered by the Plan. 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 pay for the services you received on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on October 7, 2019 to October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that it is the responsibility of the referring provider to obtain authorization. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for wound care provided on October 7, 2019 to October 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the vision care. You say that you would like reconsideration as you are unable to obtain prior authorization before rendering services. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the Plan.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aprepitant
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 Aprepitant 
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.