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

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).

You asked the Plan to pre-approve the dental items. You say that you lost your dentures while you were in the hospital. You say that you are having trouble eating and need a new set. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says that the frequency limit has been reached.

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 frequency limit for dentures has been reached. The record shows that the Plan paid for a set of dentures that you received. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp for the enrollee.
You asked the Plan to pre-approve the ramp. You say that this is necessary to get the enrollee from the house to the automobile. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a van lift for a power scooter.
You asked the Plan to pre-approve the van lift. You say that you are unable to lift your scooter due to fluid around your heart. The Plan denied your request. The Plan says this is not needed for inside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a van lift for a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heel lift (L3300).
You asked the Plan to pre-approve a heel lift. You say that a heel lift is medically necessary. The Plan denied your request. The Plan says a heel lift is not a covered benefit under your contractual policy or by Medicare for your condition.
Medicare rules state that supportive devices for the feet (such as heel lifts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although a heel lift may be appropriate for you, neither Medicare nor the Plan provides coverage of a heel lift for your condition. Therefore, we decided that the Plan does not have to pre-approve a heel lift (L3300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics (L3000 x 2).
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy or by Medicare for your condition.
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 custom foot orthotics (L3000 x 2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
You asked the Plan to pre-approve this service. You say that the service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says the service is not medically necessary for the enrollee.
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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup including any pins (D2950) teeth 21, 22 and 27.
You asked the Plan to pre-approve the dental services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not covered under the plan 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 core buildup including any pins (D2950) teeth 21, 22 and 27.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing provided on July 23, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in Illinois while the member and laboratory are located in Texas. Therefore, we decided that the Plan does not have to pay for COVID-19 testing provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital. You say that the semi-electric hospital bed is medically necessary. The Plan denied your request. The Plan says the bed requested is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital. Our reviewer says that the requested hospital bed is not medically necessary. Our physician reviewer found there is no documentation showing the patient requires frequent position changes. Position changes for pressure ulcer prevention would not require semi-electric bed equipment. 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 semi-electric hospital have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve the monitor. You say that uncontrolled high blood pressure can lead to disability, poor quality of life, or even a fatal heart attack or stroke. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of your power wheelchair to be provided by an out of network provider.
You asked the Plan to pre-approve repair of your power wheelchair. You say that you need your power wheelchair repaired. The Plan denied your request. The Plan says they have an in-network provider available to repair your power wheelchair.
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 repair of your power wheelchair to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual adult size wheelchair and accessories.
You asked the Plan to pre-approve a manual adult size wheelchair and accessories. You say that the enrollee needs a manual adult size wheelchair and accessories. The Plan denied your request. The Plan says durable medical equipment is not covered at the enrollee's present location.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a manual adult size wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a manual adult size wheelchair and accessories.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic tests provided by a participating provider on October 28, 2020.
You asked the Plan to waive the copayment for diagnostic tests. You say that you think your copayment should be $50, not $100. The Plan denied your request. The Plan says the correct 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 $100 copayment for outpatient diagnostic tests/in-network/diagnostic procedures and tests/outpatient hospital. You have been asked to pay a $100 copayment for diagnostic tests. The correct copayment has been applied to the services that were provided by a participating hospital facility. Diagnostic tests fall within the outpatient diagnostic tests/in-network/diagnostic procedures and tests/outpatient hospital 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 diagnostic tests provided by a participating provider on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the right sacroiliac joint (64625).
You asked the Plan to pre-approve this service. You say that the service is medically necessary for the enrollee. The Plan denied your request. The Plan says the service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that this procedure is experimental. More research is needed to show safety and efficacy of this treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the right sacroiliac joint (64625).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
You asked the Plan to pre-approve home visits for assistance with activities of daily living and personal care. You say that you live alone and cannot help yourself. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. The rules also say that custodial care is not covered. We looked at the file and Medicare rules. The requested services are custodial in nature. Based on this information, we decided that Medicare rules for coverage of home visits for assistance with activities of daily living and personal care have not been met. Therefore, we decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a mastectomy bra. 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 durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dialysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare 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 dialysis services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET/CT.

You asked the Plan to pre-approve PET/CT. You say that you would like reconsideration because accurate staging is an important objective in improving management and outcomes. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT. Our reviewer says that Medicare criteria have not been met. Our physician reviewer found this service can be approved for men with suspected prostate cancer recurrence after initial therapy. This service is requested as initial staging. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET/CT have not been met. Therefore, we decided that the Plan does not have to pre-approve PET/CT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider.

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 subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality test (D0460) and the cone beam CT capture with interpretation (D0364) provided on October 8, 2020.
You asked the Plan to pay for the dental services. You say that you had been experiencing pain in your tooth. You say that you thought you might have a cavity. You say that your tooth was actually cracked and possibly infected. You say that you were referred for a pulp vitality test to confirm this. You also say that you would like these services to be approved. The Plan denied your request. The Plan says pulp vitality test is not listed as a covered service. The Plan says that cone beam CT capture with interpretation is not listed as a covered service either. The Plan also says that any services not listed 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 not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the pulp vitality test (D0460) and the cone beam CT capture with interpretation (D0364) provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation-diagnostic service to be provided by a dentist or physician other than the requesting dentist or physician (D9310).
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 this service is not a covered benefit under your dental policy.
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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a consultation-diagnostic service to be provided by a dentist or physician other than the requesting dentist or physician (D9310).