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

We decided that the Plan has to pre-approve a dental extraction on tooth # 13 (D7210).
You asked the Plan to pre-approve a dental extraction on tooth # 13 (D7210). You say that the requested dental extraction on tooth # 13 is medically necessary. The Plan denied your request. The Plan says that the requested dental extraction on tooth # 13 is not medically necessary. The Plan states the x-rays do not show the need for bone removal or sectioning of the tooth. The Plan states this is needed for teeth that have formed abnormal or multiple roots or teeth with 75% of the clinical crown destroyed by decay. The Plan states a less severe extraction code would be considered.
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 a dental extraction on tooth # 13 (D7210) 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 a dental extraction on tooth # 13 (D7210). Our reviewer says that the requested dental extraction on tooth # 13 is medically necessary. Our physician reviewer found the reason for the denial was that the service was not medically necessary (as opposed to a routine extraction (D7140) per the Plan. A review of the enrollee's dental record and radiograph indicates the significant breakdown of the coronal aspect of tooth #13. This would require a more involved removal procedure than a routing extraction. Due to the significant breakdown of the coronal structure of tooth #13, the criteria for a surgical extraction (D7210) have been met. 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 a dental extraction on tooth # 13 (D7210) have been met. Therefore, we decided that the Plan has to pre-approve a dental extraction on tooth # 13 (D7210).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visits provided on September 15, 2019 and September 21, 2019.
You asked the Plan to waive the copayments for the emergency room visits. You say that you feel it is the responsibility of the skilled nursing facility. You say you were under their care when you fell. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $50 copayment for each of the emergency room visits. The emergency room visits fall within the "Emergency care" benefit category. The record shows you received services in the emergency room on both dates of service.
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 copayments for the emergency room visits provided September 15, 2019 and September 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the bowel pouch endoscopy or the specialist
office visit provided on July 15, 2019.
You asked the Plan to reduce the cost share for the endoscopy and the specialist office visit. You say that in the
past you have only paid the doctor visit only and not the procedure. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% of
the cost for all other Medicare-covered surgical services (including observation services associated with
outpatient surgery), up to $350 annual maximum out-of-pocket cost and a $35 copayment for each Medicarecovered
specialist visit.
You have been asked to pay a total cost share amount of $120.24 for the endoscopy and the specialist office
visit. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The specialist office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. See chart below.

Date of Service: July 15, 2019 
Service: Bowel pouch endoscopy
Allowed Amount: $1,408.00
Copayment/Coinsurance: 15% 
Member Liability: $85.24 - You are being charged less than the standard amount because you met your $350 out-of pocket maximum.

Date of Service: July 15, 2019 
Service: Specialist office visit
Allowed Amount: $91.08 
Copayment/Coinsurance: $35.00 
Member Liability: $35.00

Total Member Liability: $120.24

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 reduce the cost share for the bowel pouch endoscopy or the specialist office visit
provided on July 15, 2019.
Our decision is only about the July 15, 2019 services. If you have any questions about prior years billing,
please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posture cloud adjustable bed and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these items do not have an identified HCPCS code, and are not available from a Medicare-contracted provider. They do not meet the Medicare definition of DME, as they are not primarily for a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Our MAXIMUS Doctor Consultant found that the documentation does not support that these items are primarily for medical purpose. There is no evidence that these items are being furnished within the accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member. There is no evidence that these items would be effective for the enrollee's condition. The posture cloud adjustable bed and accessories are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a posture cloud adjustable bed and accessories for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the sleep study provided on August 16, 2019
You asked the Plan to pay for the sleep study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 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 sleep study provided on August 16, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on August 9, 2019 to October 28, 2019.
You asked the Plan to pay for a blood glucose monitor, test strips, lancets, calibrator solution, and a lancing device. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for a blood glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on August 9, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 9, 2018 by the out of network provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 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 office visit provided on April 9, 2018 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August
12, 2019 to October 31, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no
valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a
tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the
diabetic supplies provided to the enrollee from August 12, 2019 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell injection (0232T) you received on May 30, 2019.

You asked the Plan to pay for the stem cell injection. You say that you verified that the procedure was covered. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that LCA A56480 provides a list of noncovered codes. 

We looked at the file and Medicare rules. Per A56480, code 0232T is noncovered. The records also show that you were made aware by the provider that the services would not be covered. Based on this information, we decided that Medicare rules for coverage of the stem cell injection have not been met. Therefore, we decided that the Plan does not have to pay for the stem cell injection (0232T) you received on May 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with shortness of breath. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for congestive heart failure and atrial fibrillation. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a maximal to total assist level for functional mobility and care. She had been bed bound at baseline. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee has a relevant past medical history that includes urinary incontinence, depression, migraine headaches, insomnia, hypertension, Type II diabetes, chronic kidney disease, and gastroesophageal reflux disease. She is currently at home and has a history of frequent falls with increased weakness, gait instability, and knee buckling. She has reported difficulty performing activities of daily living for the past few weeks and a decline in functional mobility. The enrollee lives alone in a second floor apartment with elevator access and has been independent with durable medical equipment including a Rollator walker or cane. The enrollee has a normal body mass index. Functionally, she requires minimum assistance with bed mobility, transfers, and when ambulating an unspecified distance. She requires supervision for upper body and up to minimum assistance for lower body dressing. Based on the documentation provided, the enrollee reports frequent falls and is currently in a home-based setting as described above. The enrollee's medical conditions appear stable. There are no wound care needs. She is in the outpatient setting and does not require medical oversight of her condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and an occupational therapy evaluation is indicated for remaining activities of daily living and adaptive equipment. However, she does not require an intensive therapy program. The enrollee should be able to fully participate in and benefit from the required intensity of
an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing test (92557) provided on August 27, 2019 by the out of network provider.
You asked the Plan to pay for a hearing test. You say that you are appealing the claim payment denial for services rendered to your member on date of service August 27, 2019. The Plan denied your request. The Plan says the doctor is a non-participating provider. The Plans says it did not authorize any services for the out of network provider. The Plan says there are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The Plan also says that services are not considered urgent/emergent in nature.
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 a hearing test (92557) provided on August 27, 2019 by the out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 outpatient physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says the therapist has requested more therapy visits than recommended by criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 visits. Our reviewer says that skilled
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.
Our physician reviewer found the requested therapy additional therapy is not generally accepted as specific and
effective therapy for the enrollee's condition beyond what was approved by the health plan. The documentation
does not reveal the need for the additional 16 therapy visits without evidence of efficacy or continued need
after prior approved therapy. Additionally the enrollee is participating in an independent home exercise
program. The records do not demonstrate that the unique skills of a professional therapist are required to safely
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist,
or under the supervision of a therapist. The requested services are not part of a maintenance program, and the
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve 24 outpatient physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Face Down Positioning Device purchased on April 24, 2019.
You asked the Plan to pay for the item. You say that you believe this should be covered because it was recommended to you after your eye surgery by the ophthalmologist. The Plan denied your request. The Plan says you were advised on April 8, 2019, before you purchased the item, that this is not a Medicare covered durable medical equipment benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. These devices are statutorily noncovered because they do not fall within a Medicare benefit category. They are considered "precautionary devices" and the equipment can be used for purposes other than the treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for Face Down Positioning Device purchased on April 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0272) provided on August 20, 2019.
You asked the Plan to pay for the dental service. You say that the Evidence of Coverage does not specify what type of x-rays are covered. The Plan denied your request. The Plan says bitewings are 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 bitewing x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0272) provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) provided on July 2, 2019.
You asked the Plan to pay for the services. You say that you should not be charged for your annual exam. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Per page 93 of your benefit book, routine eye exams (refractions) are not covered by Medicare. Your benefits are only for Medicare covered services. Therefore, we decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) provided on July 2, 2019.