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

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested item have not been met.
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 a semi-electric hospital bed. Our reviewer says that this item is not medically necessary and reasonable. Our physician reviewer found the documentation does not clearly reveal that patient's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation (A0100) provided on November 25, 2020. You asked the Plan to pay for non-emergency transportation. You say that you did not utilize the Plan's vendor for transportation because they are unreliable. The Plan denied your request. The Plan says you did not utilize the transportation benefit. There is no record of you requesting transportation services from the Plan's vendor.
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 routine transportation when the Plan's transportation vendor is utilized. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency transportation (A0100) provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism and recliner chair. You asked the Plan to pre-approve a seat lift mechanism and recliner chair. You say that these items are medically necessary. The Plan denied your request. The Plan says the requested seat lift is not likely to improve, arrest, or retard your condition.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. The rules also say that for equipment to be covered, it must primarily serve a medical purpose. 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 seat lift mechanism and recliner chair. Our reviewer says that the requested seat lift mechanism is not medically necessary and reasonable. Our physician reviewer found the documentation does not reveal objective evidence of severe arthritis of the hip or knee; and/or a neuromuscular disease. The practitioner note indicated the patient requests and is interested in obtaining a seat lift. The seat lift is not likely to effect improvement in your condition; or (b) arrest or retard deterioration in your condition. The patient has the ability to ambulate. The criteria for a seat lift mechanism have not been met. Furthermore, the recliner chair 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism and recliner chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism and recliner chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), a panoramic radiographic image (D0330) and periapical first radiographic image (D0220) provided on April 26, 2021.
You asked the Plan to pay for dental codes D0140, D0330, and D0220. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0140, D0330, and D0220 are not covered under the Plan's supplemental dental 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, dental codes D0140, D0330, and D0220 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), a panoramic radiographic image (D0330) and periapical first radiographic image (D0220) provided on April 26, 2021. Your complaint about being charged twice for the same service 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (V2788) provided May 4, 2021.
You asked the Plan to pay for the presbyopia correcting function of intraocular lens. You say that this procedure was necessary for your continued vision. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan doe
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ground ambulance transport services
provided on May 25, 2021.
You asked the Plan to waive the copayment for ground ambulance transport services. You say that you were
forced to get into the ambulance. You say you would like for this bill to be deleted. 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 $235
copayment for ground ambulance services. You have been asked to pay a $235 copayment for ground ambulance transport services. Ground ambulance
transport services fall within the Ambulance 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
copayment for ground ambulance transport services provided on May 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Gel-One (J7326) and the arthrocentesis (20160) provided on January 4, 2021.
You asked the Plan to pay for injection. You say that the services are medically necessary. The Plan denied your request. The Plan says the clinical value of Gel-One in the setting of a meniscal tear has not been demonstrated in the peer-review literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 pay for injection. Our reviewer says that the injection is not medically necessary. Our physician reviewer found use of Gel-One is not FDA-approved for the enrollee's diagnosis. The reviewer found that the use of Gel-One is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the injection is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection have not been met. Specifically, the use of the injection is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pay for Gel-One (J7326) and the arthrocentesis (20160) provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an unspecified preventive procedure (D1999), intraoral periapical radiographic images (D0220, D0230), a periodic oral evaluation (D0120), and periodontal maintenance (D4910) provided from July 10, 2020, through January 19, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, a teeth cleaning, an unspecified preventive procedure, intraoral periapical radiographic images, a periodic oral evaluation, and periodontal maintenance. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a teeth cleaning, an unspecified preventive procedure, intraoral periapical radiographic images, a periodic oral evaluation, and periodontal maintenance have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), an unspecified preventive procedure (D1999), intraoral periapical radiographic images (D0220, D0230), a periodic oral evaluation (D0120), and periodontal maintenance (D4910) provided from July 10, 2020, through January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stays from December 16, 2020, through December 20, 2020, and December 26, 2020, through January 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stays. You say that you cannot afford the cost of the services and have never had to pay so much for inpatient stays in the past. The Plan denied your request. The Plan says the copayments were applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per day, days 1-7 for Medicare covered hospital stays up to the $1,575 out-of-pocket limit per benefit period. You have been asked to pay $900 for the hospital stay from December 16, 2020, through December 20, 2020 ($225 copayment x 4 days = $900) and a $625 copayment for the hospital stay from December 26, 2020, through January 1, 2021 ($225 copayment x 6 days = $1,350 however the out-of-pocket limit was reached so you were only charged $625). You were asked to pay a total of $1,575 for the two inpatient hospital stays. Inpatient hospital stays fall within the Inpatient hospital care 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 the inpatient hospital stays from December 16, 2020, through December 20, 2020, and December 26, 2020, through January 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), bitewing radiographic images (D0274), and topical application of fluoride varnish (D1206) provided on March 31, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, bitewing radiographic images, and topical application of fluoride varnish. You say that the services should be covered. The Plan denied your
request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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 periodic oral evaluation, a teeth cleaning, bitewing radiographic images, and topical application of fluoride varnish have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), bitewing radiographic images (D0274), and topical application of fluoride varnish (D1206) provided on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate-specific membrane antigen (PMSA) scan.
You asked the Plan to pre-approve a PMSA scan. You say that the services are necessary. The Plan denied your
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a PMSA scan. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found you have not had definitive therapy to establish the necessity for Axumin scan looking for
recurrence. The potential enrollment in a trial of Radioligand therapy is not an indication as such therapy is not
FDA approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PMSA scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prostate-specific membrane antigen (PMSA) scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the removal of recurring cataract in lens capsule using a laser (66821) provided April 16, 2021.
You asked the Plan to waive the copayment the removal of recurring cataract in lens capsule using a laser. You say that you do not agree with the copayment as charged. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $260 copayment for Medicare-covered outpatient hospital procedure or surgery. You have been asked to pay a $260 copayment for the removal of recurring cataract in lens capsule using a laser. This service falls within the Medicare-covered outpatient hospital procedure or surgery benefit category. We decided that the Plan does not have to waive the copayment the removal of recurring cataract in lens capsule using a laser (66821) provided April 16, 2021.
You asked the Plan to waive the copayment the removal of recurring cataract in lens capsule using a laser. You say that you do not agree with the copayment as charged. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $260 copayment for Medicare-covered outpatient hospital procedure or surgery. You have been asked to pay a $260 copayment for the removal of recurring cataract in lens capsule using a laser. This service falls within the Medicare-covered outpatient hospital procedure or surgery benefit category.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March
15, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that the service should be covered.
The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the
frequency limit of one every 3 Plan years.
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 comprehensive oral evaluation have not been met. Specifically, the record shows that you had
exceeded the frequency limit prior to this service on February 10, 2020. Therefore, we decided that the Plan
does not have to pay for a comprehensive oral evaluation (D0150) provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2020.
You asked the Plan to pay for the laboratory 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2394), endodontic therapy (D3310), prefabricated post and core in addition to crown (D2954), and a pulp cap - indirect (D3120) provided from April 8, 2021, through April 15, 2021.
You asked the Plan to pay for a filling, endodontic therapy, prefabricated post and core in addition to crown, and a pulp cap - indirect. You say that the services should be covered. The Plan denied your request. The Plan says the filling is a covered benefit, but you have exceeded the frequency limit of 2 per calendar year. The Plan also says that endodontic therapy, prefabricated post and core in addition to crown, and a pulp cap - indirect 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling, endodontic therapy, prefabricated post and core in addition to crown, and a pulp cap - indirect have not been met. Specifically, the record shows that you had exceeded the frequency limit for fillings. Additionally, endodontic therapy, prefabricated post and core in addition to crown, and a pulp cap - indirect are not covered benefits. Therefore, we decided that the Plan does not have to pay for a filling (D2394), endodontic therapy (D3310), prefabricated post and core in addition to crown (D2954), and a pulp cap - indirect (D3120) provided from April 8, 2021, through April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210), the comprehensive oral evaluation (D0150), and the 2D oral/facial photographic image (D0350) provided on March 30, 2021.
You asked the Plan to pay for dental codes D0210, D0150, and D0350. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says one intraoral-complete series of radiographic images (D0210) is covered once every 5 years. Also, one comprehensive oral evaluation (D0150) is covered once every 3 years. Reimbursement was previously issued for date of service January 14, 2021 for these same services, which is less than three years ago. Furthermore, a 2D oral/facial photographic image (D0350) is not covered under the Plan's supplemental dental 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. We looked at the file and the Plan's contract. The file shows one intraoral-complete series of radiographic images (D0210) is covered once every 5 years. Also, one comprehensive oral evaluation (D0150) is covered once every 3 years. Reimbursement was previously issued for date of service January 14, 2021 for these same services, which is less than three years ago. Furthermore, a 2D oral/facial photographic image (D0350) is not covered under the Plan's supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210), the comprehensive oral evaluation (D0150), and the 2D oral/facial photographic image (D0350) provided on March 30, 2021.