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

We decided that the Plan does not have to pay an additional amount for deluxe frames provided on
February 24, 2021.

You asked the Plan to pay an additional amount for the deluxe frames. You say that the initial claim was for
lenses and frames due to cataract surgery and should be covered in full, with no cost to you. The Plan denied
your request. The Plan says any upgrades including deluxe frames are not a covered benefit. The negotiated
charge for the deluxe frames was $176.00 after which the Plan paid the provider $120 and balance billed to you
is $56 coinsurance.

Medicare says only standard frames (V2020) are covered. Additional charges for deluxe frames (V2025) will
be denied as non-covered. The Plan contract says that any eyewear upgrades are not covered.

We looked at the file, the Plan's rules and the Medicare rules. The file shows that the Plan does not cover
upgrades including deluxe frames. Medicare says only standard frames are covered. Therefore, we decided that
the Plan does not have to pay an additional amount for deluxe frames provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on April 12, 2021. 
 
You asked the Plan to pay for chiropractic services. You say that you do not understand why these services 
were denied as they should be covered. The Plan denied your request. The Plan says any services not directly 
related to manual manipulation of the spine are not covered. 
 
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. The records show that the services at issue are not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the Vertiflex procedure is considered experimental and investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy before this service will be covered. 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve a group 3 power wheelchair. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on May 5, 2021.
You asked the Plan to pay for the crown. You say that you were told that crowns and fillings would be covered at 50% The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 pay for the crown (D2740) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair and related accessories.
You asked the Plan to pre-approve a lightweight wheelchair and related accessories. You say that the medical records provided support the need for the requested items. The Plan denied your request. The Plan says backup wheelchairs are not considered medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a group 2 power wheelchair. A group 2 power wheelchair serves the same purpose as a lightweight wheelchair. If the base wheelchair is not considered medically necessary, the related supplies are also not considered medically necessary. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair and related accessorie
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dalvance.
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 step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a surgical site infection. He has not tried and failed the Plan's required drug of an appropriate antibiotic. The records do not show that the required drugs would be contraindicated or less effective; therefore, Dalvance is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Dalvance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 10, 2020.
You asked the Plan to pay for the surgical extraction. You say that this service should have been billed as a simple extraction. The Plan denied your request. The Plan says this service is not covered under your 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. The only type of extractions covered under your plan are simple extractions. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, prophylaxis, and resin-based composite provided on May 11, 2021, and June 7, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, prophylaxis, and resin-based composite. You say that the Plan stopped covering services rendered by OON providers without notification to you. You also say that you stayed with this insurance plan because they offered coverage with OON dental providers in October 2020. The Plan denied your request. The Plan says you must receive services at a participating provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewing x-rays, prophylaxis, and resin-based composite provided on May 11, 2021, and June 7, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not failed other treatments.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the requirements for coverage of Evenity have not been met. Our physician reviewer found Evenity is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. In this case, the enrollee has not tried any other osteoporosis therapies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services to be provided at the in-network benefit level by an out-of-network (OON) provider.

You asked the Plan to pre-approve urology services. You say that this provider is the only surgeon who does the needed HolEP procedure in the state. The Plan denied your request. The Plan says the denial of authorization for in-network benefits for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider. The Plan also says that you may elect to see this provider using your out-of-network benefits.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees may choose to receive care from out-of-network providers, but the costs for covered services may be higher than the in-network benefit level. 

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 at the in-network benefit level. You may choose to receive services from this provider using the Plan's out-of-network benefits. Therefore, we decided that the Plan does not have to pre-approve urology services to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided from July 23, 2020, to March 26, 2021.
You asked the Plan to pay for naturopathic services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says a naturopathic service are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for services provided from July 23, 2020, to March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88341, 88342) rendered by the out-of-network (OON) provider on March 1, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.

The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (88341, 88342) rendered by the out-of-network (OON) provider on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out-of-network (OON) provider on June 12, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out-of-network (OON) provider on June 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee from January 20, 2021, to January 30, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee from January 20, 2021, to January 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound cleaner for the enrollee.
You asked the Plan to pre-approve wound cleaner. You say that this product would be beneficial for the enrollee. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare does not cover supplies that are hygienic or non-reusable. While wound cleaner may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve wound cleaner for the enrollee.
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 February 4, 2021, to February 10, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this copayment. 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 $300 copayment per admission for inpatient hospital services. You have been asked to pay a $300 copayment for the inpatient hospital services. 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 February 4, 2021, to February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are unable to take care of yourself and are out of state. The Plan denied your request. The Plan says the enrollee does not need complex rehabilitation or nursing needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick urine collection system.
You asked the Plan to pre-approve the PureWick urine collection system. You say that the device 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 for female external urinary collection devices, more than one meatal cup (A4327) per week or more than one pouch (A4328) per day will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The requested device is not the covered meatal cup or pouch type collection device. Based on this information, we decided that Medicare rules for coverage of the PureWick urine collection system have not been met. Therefore, we decided that the Plan does not have to pre-approve a PureWick urine collection system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig purchased on January 14, 2021.

You asked the Plan to pay for a wig. You say that you are a cancer patient and you were not given clear direction as to whether or not the wig was covered. In a letter sent directly to Maximus you stated that while this may be considered a comfort or convenience item, when you are undergoing cancer treatments, a comfort or convenience item is imperative for successful treatment outlook. The Plan denied your request. The Plan says wigs are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that wigs do not serve a purpose that is primarily medical in nature. While this item may have been beneficial for you to use, wigs are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a wig purchased on January 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on May 8, 2021
.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were shopping, and you passed out in the store due to low blood sugar. You say the ambulance was called and by the time they arrived you had come to and were given orange juice and were feeling better. You say that the ambulance service took your vitals and together they decided you did not need to be transported to the hospital. The Plan denied your request. The Plan says the ambulance services without transport is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on May 8, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on May 8, 2021.