Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 5, 2020 and November 9, 2020.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services provided on October 5, 2020 and November 9, 2020.

Your complaint about being provided the incorrect information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to remove the enrollee's responsibility for the charges for services provided on January 10, 2018.

You asked the Plan to remove the enrollee's responsibility for the charges for the laboratory, EKG, Echocardiography, and clinic services. You say that the surgery was approved so the follow-up visit should be covered. The Plan denied your request. The Plan says that services were denied because the provider is out of network.

The Plan must follow Medicare rules. Medicare rules say that billing is not allowed for services that are included in the global package.

We looked at the file and Medicare rules. The enrollee had an approved surgery, and these services were provided at a follow up visit. This follow up visit is under the Global Package. Based on this information, we decided that Medicare rules for coverage of the laboratory, EKG, Echocardiography and clinic services have not been met. The provider billed improperly. Therefore, we decided that the Plan has to remove the enrollee's responsibility for the charges for services provided on January 10, 2018.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one additional home care occupational therapy visit.

You asked the Plan to pre-approve the additional visit. You say that this is medically necessary. The Plan denied your request. The Plan says there is no current need for a skilled level of intermittent occupational therapy.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 visit. Our reviewer says that the requested visit is not medically reasonable or necessary. Our physician reviewer found the documentation does not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your functional level does not require the professional skills of an occupational therapist. You have had instruction on a home exercise program and safety.

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 visit have not been met. Therefore, we decided that the Plan does not have to pre-approve one additional home care occupational therapy visit.
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 foot orthotics. You say that this is needed to prevent future ulcerations, pain, and deformity. 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. 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 foot orthotics.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve thyroid nuclear imaging.

You asked the Plan to pre-approve thyroid nuclear imaging. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve thyroid nuclear imaging. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a history of lymphoma that increases his risk for thyroid cancer. Regardless of laboratory test results, nuclear imaging for this enrollee would be medically reasonable and necessary as defined by Medicare rules. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thyroid nuclear imaging have been met. Therefore, we decided that the Plan has to pre-approve thyroid nuclear imaging.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the lower extremity provided on September 10,
2020.

You asked the Plan to pay for the CT scan. You say that you would like to appeal this service. The Plan denied
your request. The Plan says the enrollee became effective under hospice care during this time. The Plan also
says that the provider needs to bill traditional Medicare for this service.

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 the CT of the lower extremity provided on September 10,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve pain management services. You say that you would like approval for these services to be provided by an out-of-network provider. 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 pain management 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-approve a bone replacement graft for ridge preservation
(D7953), custom abutment (D6057), implant placement (D6010), implant supported crown (D6065),
prosthodontics fixed, pontic (D6245 x2), and crown retainers (D6740 x4).
You asked the Plan to pre-approve a bone replacement graft for ridge preservation, custom abutment, implant
placement, implant supported crown, prosthodontics fixed, pontic, and crown retainers. You say that you
cannot afford to pay for these services out of pocket. The Plan denied your request. The Plan says these
services are not covered benefits.
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
bone replacement graft for ridge preservation (D7953), custom abutment (D6057), implant placement (D6010),
implant supported crown (D6065), prosthodontics fixed, pontic (D6245 x2), and crown retainers (D6740 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5226).

You asked the Plan to pre-approve a lower partial denture. You say that the service was covered for you in the
past and you need it covered again. The Plan denied your request. The Plan says the service is a covered
benefit, but the benefit has been 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a lower partial denture have not been met. Specifically, the record shows that you had exceeded the
frequency limit. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5226).
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 this has been prescribed from your doctor for medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax.

You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says a CT scan is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scan. Our reviewer says that a CT scan is not medically reasonable and necessary in this case. Our physician reviewer found that the medical records provided do not indicate a reason for the requested CT scan. There is no evidence in the medical record of a lung nodule. The requested service cannot be considered medically reasonable and necessary based upon the information provided. The elements of the coverage rule criteria are no 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling in presence of mild or severe gingival
inflammation (D4346).

You asked the Plan to pre-approve the dental service. You say that it is very hard for the enrollee to brush her
teeth. You say that this service should be covered. The Plan denied your request. The Plan says scaling in
presence of mild or severe gingival inflammation 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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
scaling in presence of mild or severe gingival inflammation (D4346).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan Hycela.

You asked the Plan to pre-approve Rituxan Hycela. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Rituxan Hycela. Our reviewer says that
the documentation supports that the requested drug is medically reasonable and necessary. Our physician
reviewer found the enrollee has received three doses of Rituxan for auto immune hemolytic anemia. The
requested Rituxan Hycela for the last dose Rituxan is allowed as a substitution and is reasonable and necessary.
Therefore, the enrollee meets criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituxan Hycela have been met. Therefore, we decided that the Plan has to pre-approve
Rituxan Hycela.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an OON provider.

You asked the Plan to pre-approve physician services. You say that you would like approval for these services
to be provided 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
physician services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery and copayment for
physical therapy and occupational therapy provided by a participating provider on November 24, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery and copayment for physical therapy and
occupational therapy. You say that you signed a paper that said your total would be $380. You say that you do
not agree with these additional charges. The Plan denied your request. The Plan says the correct coinsurance
and copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for outpatient surgery and a $40 copayment for outpatient rehabilitation services.

You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery, and less than a
$40 copayment for physical therapy and occupational therapy. The total allowed amount is $10,913.90. The
total amount you are being asked to pay for an outpatient surgery is $2,182.78 ($10,913.90 x 20% =
$2,182.78). The total amount you are being asked to pay is $2,213.78 ($2,182.78 + $12.96 + $18.04 =
$2,213.78). An outpatient surgery falls within the outpatient surgery benefit category. Physical therapy and
occupational therapy fall within the outpatient rehabilitation services benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance and copayment for an outpatient surgery, physical therapy, and
occupational therapy provided by a participating provider on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.

You asked the Plan to pre-approve a mastectomy sleeve. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the required criteria has not been met.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you only take insulin twice a day. The insulin is not frequently adjusted based on the glucose readings. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinus augmentation (D7261), an initial 15 minutes of deep sedation (D9222), and an additional 15 minutes of deep sedation (D9223).
You asked the Plan to pre-approve the dental services. You say that You say that you need this service. You also say that when you eat or drink, the food and drink come up your nose and into the mouth causing you to choke. You also say that you cannot use dentures until this procedure is completed. The Plan denied your request. The Plan says that sinus augmentation is not listed as a covered service. The Plan says that the provider has not submitted the required documentation to support the need for treatment. The Plan also says that this does not meet the plan requirements that require all treatment to be medically necessary.
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 sinus augmentation is not among those covered under this benefit. Additionally, the necessary documentation was not provided to show that the deep sedation services were medically necessary. Therefore, we decided that the Plan does not have to
pre-approve a sinus augmentation (D7261), an initial 15 minutes of deep sedation (D9222), and an additional 15 minutes of deep sedation (D9223).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that an MRI of the lumbar spine is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is known to have previous lumbar injections for pain. The medical record does not indicate any recent trauma. The recorded physical examination is neurologically normal. The provided documentation does not indicate a need for a lumbar MRI. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.