Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom shoes.You asked the Plan to pre-approvecustom shoes. You say that you have nerve damage on thepads of your feet that is not due to diabetes.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 custom shoes may be appropriate for you, neither Medicare nor the Plan provides coverage of the custom shoes for your condition.Therefore, we decided that the Plan does not have to pre-approvecustom shoes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positioning chair and cushion (E0190) (A9270).You asked the Plan to pre-approvethe positioning chair and cushion. You say that you are to have vitrectomy surgery on February 19, 2020, you have had surgery before, and the chair will allow you to be facing downwards as needed.The Plan denied your request. The Plan says this item is statutorily excluded.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.Therefore, we decided that the Plan does not have to pre-approvea positioning chair and cushion (E0190) (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional 11 surgical extractions (D7210) of teeth # 2, 3, 4, 5, 6, 7, 9, 11, 13, 14 and 15, and the immediate upper denture (D5130) provided on March 29, 2019.You asked the Plan to pay forthe 11 additional extractions and the immediate dentures. You say that you called the Plan prior to having receiving the services. You say that you asked about the dollar amount that the Plan would pay. You also say that you were advised $2,000 would be paid.The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan says the frequency limit for extractions has been exceeded. The Plan also says dentures are not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicarecoverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 2 of the extractions you received on March 29, 2019. Additionally, dentures are not a covered service.Therefore, we decided that the Plan does not have to pay forthe additional 11 surgical extractions (D7210) of teeth # 2, 3, 4, 5, 6, 7, 9, 11, 13, 14 and 15, and the immediate upper denture (D5130) provided on March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providepower wheelchair electronic connection, and expandable controller harness.You asked the Plan to provideelectronic connection (E2311), Expandable controller harness (E2313). You say that the enrollee needs the upgraded electronicsto control the tilt system. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary.The Plan follows Medicare rules. Medicare rules say that options are covered if medically necessary.Documentation shows that the enrollee has normal range of motion and 5/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. This means that Medicare rules for coverage of upgraded electronicshave not been met.Therefore, we decided that the Plan does not have to providepower wheelchair electronic connection, and expandable controller harness.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea retroperitoneal ultrasound for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not supported.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The documentation does not support that the ultrasound is reasonable and medicallynecessary at this time. 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-approvea retroperitoneal ultrasound for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) and a hepatitis A and B vaccine (90636) provided on September 26, 2019.You asked the Plan to pay fora shingles vaccine and a hepatitis A and B vaccine. You say that these vaccines were medically necessary.The Plan denied your request. The Plan says coverage of these vaccines is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and a hepatitis A and B vaccine. The Plan follows the same rules. Records do not showthat you have been injured or directly exposed to any illness related to a shingles vaccine and a hepatitis A and B vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) and a hepatitis A and B vaccine (90636) provided on September 26, 2019.Benefits for a shingles vaccine and a hepatitis A and B vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea cane (E0105).You asked the Plan to pre-approvethe cane. The Plan denied your request. The Plan says Medicare coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that canes are covered when the enrollee has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home, is able to safely use the cane, and the functional mobility deficit can be sufficiently resolved by use of a cane or crutch.We looked at the file and Medicare rules. In this instance, the documentation does not support that the enrollee has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADL in the home. Based on this information, we decided that Medicare rules for coverage of the cane have not been met.Therefore, we decided that the Plan does not have to pre-approvea cane (E0105).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe customization of a removable dental prosthetic (D5899) and the complete upper denture (D5110) provided on November 14, 2019.You asked the Plan to reimburse you forthe customization of a removable dental prosthetic. You say that you paid for $600.69 for the upper denture. You also say that you would like to be reimbursed.The Plan denied your request. The Plan says the customization of a removable dental prosthetic is not a covered service.The Plan also says there is a 70% copayment for dentures.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 customization of a removable partial dental prosthetic is not among those covered under this benefit.Additionally, the record shows that the Plan paid the 30% cost share for the upper denture. The Evidence of Coverage clearly states there isa 70% copayment for dentures.Therefore, we decided that the Plan does not have to reimburse you forthe customization of a removable dental prosthetic (D5899) and the complete upper denture (D5110) provided on November 14, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveexercise equipment.You asked the Plan to pre-approveexercise equipment. You say that you would like to have this exercise equipment to exercise your feet and legs.The Plan denied your request. The Plan says this is not a covered 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.Therefore, we decided that the Plan does not have to pre-approveexercise equipment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider for BRCA genetic testing.You asked the Plan to pre-approvethese services. You say that you have a historyof cancer and want to know if it is genetic.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network provider for BRCA genetic testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from June 21, 2019 at 6:09pm through June 23, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 pay for inpatient hospital care. Our physician reviewer found the review indicates that all inpatient care provided after 6:08 pm on June 21, 2019 through 2:07 pm on June 23, 2019 was not needed on an emergent basis.  At this time, the enrollee had ruled out for an acute cardiac condition and is clearly stable for transfer to a facility for further treatment. As of this time the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility for observation/admission level of care services. There wasno documentation provided necessitating post-stabilization care services after 6:08 pm on June 21, 2019 through 2:07 pm on June 23, 2019 at the non-plan facility.The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from June 21, 2019 at 6:09pm through June 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea surgical extraction(D7210) and a consultation including oral evaluation (D9310) with an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that you saw a dentist in 2018. You say that your tooth was not as broken then as it is now. You also say that you need this tooth pulled because your face is swollen and you are in pain.The Plan denied your request. The Plan says dental services mustbe performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, dental services must be performed by a participating general dentist in order to be covered. Services performed by an oral surgeon are not covered.Therefore, we decided that the Plan does not have to pre-approvea surgical extraction (D7210) and a consultation including oral evaluation (D9310) with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical implant body placement (D6010).You asked the Plan to pre-approvethe surgical implant body placement (D6010). You say that you were informed your dental coverage would increase. You say that you were informed it would be covered if it was resubmitted with the correct code.The Plan denied your request. The Plan says the service is not a covered benefit.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-approvethe surgical implant body placement (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve288 additional tripsfor routine transportation.You asked the Plan to pre-approvethe additional trips. You say that you receive dialysis treatments 3 days a week and you are requesting a total of 288 trips for the dialysis appointments. You are on a fixed income and the cost would cause a financial burden.The Plan denied your request. The Plan says this request exceeds the transportation benefit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve288 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevisual fieldtesting (038T)You asked the Plan to pre-approvethe visual field testing. You say that this test is currently a Medicare covered diagnostic test and is medically necessary for patients at risk of vision loss from choroidal neovascularization.The Plan denied your request. The Plan says this service is not covered by Medicare. Enrollee's must receive their medical services from an in-network provider.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. This service is excluded under Medicare. Based on this information, we decided that Medicare rules for coverage of the visual field testing have not been met.Therefore, we decided that the Plan does not have to pre-approvevisual field testing (038T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of the CPAP.You asked the Plan to pre-approvecontinued useof the CPAP. You say that you figured out how to wear the CPAP and need more time using it.The Plan denied your request. The Plan says there is no physician face-to-face and you are not compliant.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued use of the CPAP have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of the CPAP.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea percutaneous laminotomy/laminectomy (0275T).You asked the Plan to pre-approvea percutaneous laminotomy/laminectomy. You say that this treatment is clinically supported and medically necessary.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. Medicare rules say that Percutaneous Laminotomy/Laminectomy (interlaminar approach) for decompression of neural elements is not reasonable and necessary. The rules also say 0275T has been determined to be eligible for coverage ONLY under clinical trials and or IDE studies.We looked at the file and Medicare rules. The requested service is considered not reasonable and necessary. The record does not show the enrollee is enrolled in a clinical trial for this service. Based on this information, we decided that Medicare rules for coverage of a percutaneous laminotomy/laminectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvea percutaneous laminotomy/laminectomy (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you have seen this doctor in the past.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe posterior bridge provided.You asked the Plan to pre-approvethe posterior bridge. You say that you want to have your teeth finished.The Plan denied your request. The Plan says the services are not 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. The Plan covers the posterior bridge when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the posterior bridge. Our reviewer says that the criteria for coverage has not been met.Our physician reviewer found that tooth #13 is a posterior tooth and would not be coveredfor a fixed bridge. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the posterior bridgehave not been met.Therefore, wedecided that the Plan does not have to pre-approvethe posterior bridge provided.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora hospital physician evaluation provided on February 4, 2019.You asked the Plan to pay forphysician service. You say that the enrollee presented to the emergency room and was later admitted to the hospital, and this hospital requested your provider to evaluate and treat the enrollee.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case.Therefore, we decided that the Plan has to pay fora hospital physician evaluation provided on February 4, 2019.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe porcelain/ceramic crown (D2740) and post and core in addition to crown (D2952).You asked the Plan to pre-approvethe porcelain/ceramic crown (D2740) and post and core in addition to crown (D2952). You say that the provisional filling broke in two days. You say that you don't have the resources to pay.The Plan denied your request. The Plan says the 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 coveredunder this benefit.Therefore, we decided that the Plan does not have to pre-approvethe porcelain/ceramic crown (D2740) and post and core in addition to crown (D2952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the orthotics are medically necessary for this enrollee.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 inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The Plan follows these same rules.We looked at the file and Medicare rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.