Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD).
You asked the Plan to pre-approve PILD. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not enrolled in a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study for beneficiaries with LSS who are enrolled in an approved clinical study. We looked at the file and Medicare rules. The record does not show that the enrollee is enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for coverage of PILD have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you need a raised toilet seat. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that the enrollee needs the monitor to ensure that her pressure does not elevate and it is needed for the prevention of another heart attack. The Plan denied your request. The Plan says this service 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 automatic blood pressure monitor (A4670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive hearing test (92557) and hearing aid fitting/checking (V5011) provided November 15, 2019.You asked the Plan to pay forthe hearing aid fitting/checking. You say that you are requesting reconsideration of the denial of coverage.The Plan denied your request. The Plan says enrollee's must receive their hearing services from a TrueHearing provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only Enrollee's must see a TruHearing provider. For hearing services to be covered enrollee's must go to a TruHearing provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid fitting/checking have not been met.Therefore, we decided that the Plan does not have to pay forcomprehensive hearing test (92557) and hearing aid fitting/checking (V5011) provided November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 12, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not see a specialist. You say you saw a nurse practitioner one day and a physician's assistant on another day. 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 $15 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $15 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is a Urologist.
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 specialist office visit on November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of your health problem.
The Plan must follow Medicare rules. Medicare rules say that CPT 0421T is not a covered code. The requested procedure is coded with a CPT 0421T. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on May 24, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 a domiciliary, rest home visit provided on May 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services and
outpatient rehabilitation services rendered to the enrollee from June 20, 2019 to August 16, 2019.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges.
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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $275 copayment for Medicare-covered outpatient hospital and observation services and a $25
copayment for Medicare-covered outpatient rehabilitation services.
Review of the file shows that the enrollee received outpatient hospital services on June 20, 2019. The enrollee
has been asked to pay a $275 copayment for these services. These services fall within the Medicare-covered
outpatient hospital and observation services benefit category. This means that the enrollee has been asked to
pay the correct amount based on the contract with the Plan.
The file shows that the enrollee received outpatient hospital services on July 18, 2019. Per the Plan contract,
there is a $275 copayment for these services; however, the Medicare allowed amount was $53.75. Given that
the allowed amount was less than the $275 copayment, the enrollee has been asked to pay $53.75 for these
services.
The file shows that the enrollee received outpatient hospital services and outpatient rehabilitation services on
August 16, 2019. The enrollee has been asked to pay a $275 copayment for the outpatient hospital services and a $25 copayment for the outpatient rehabilitation services. This means that the enrollee has been asked to pay
the correct amount based on the contract with the Plan.
The total amount the enrollee has been asked to pay is $628.45. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive
the copayments for the outpatient hospital services and outpatient rehabilitation services rendered to the enrollee
from June 20, 2019 to August 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The
Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the services are not medically necessary. Our physician reviewer found the enrollee is currently
undergoing treatment at an acute care hospital (ACH) for pancreatitis complicated by a duodenal perforation.
The enrollee has undergone abdominal surgery. The enrollee is not intubated/ventilated. There is no evidence
that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on November 4, 2019.You asked the Plan to pay forthe limited oral evaluation and intraoral periapical x-rays. The Plan denied your request. The Plan says these services are not covered under your plan.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 pay forthe limited oral evaluation, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removable prosthodontic procedure and complete maxillary denture provided on September 30, 2019.You asked the Plan to pay forthe removable prosthodontic procedure and complete maxillary denture. You say that the enrollee is unable to wear the teeth that were made for her. You also say the bill was paid in full but they added $29 more after the amount was paid in full.The Plan denied your request. The Plan says the enrollee has reached their annual maximum 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 Plan offers a $650 allowance for combined preventive and comprehensive dental services. The record shows that you met the annual allowance benefit on September 30, 2019 and your annual allowance benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe removable prosthodontic procedure and complete maxillary denture provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943)
provided by  on October 1, 2019 and October 21, 2019.
You asked the Plan to pay for the extra-spinal chiropractic manipulative treatment. You say that you are
requesting a reconsideration of the Plan's denial for payment of these services. The Plan denied your request.
The Plan says these services are not a covered benefit by Medicare or your health plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not covered by Medicare. Therefore, we decided that the Plan
does not have to pay for the extra-spinal chiropractic manipulative treatment (98943) provided October 1, 2019
and October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have medical insurance and that if it covers the requested services for other people then it should not have been denied. You say that you have back issues and are unable to bend or stand for long periods of time. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT)
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has high risk prostatic
T1cN0 adenocarcinoma. SBRT is considered controversial for a diagnosis of high risk prosate cancer. It is not
the standard of care and is not reasonable or medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. 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-approve stereotactic body radiation therapy (SBRT)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network immunotherapy provider.
You asked the Plan to pre-approve these services. You say that you were redirected to a provider seven miles further away. 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-approve a referral to an out-of-network immunotherapy provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 12, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 medical services provided on April 12, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 15, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 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 forthe medical services provided to the enrollee by an out-of-network provider on August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #7.
You asked the Plan to pre-approve the crown. You say that the provider cannot fix this tooth properly without
the crown since the tooth will have a root canal. The Plan denied your request. The Plan says this service
exceeds the maximum count allowed per period.
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, crowns, inlays, and onlays are limited
to one procedure per tooth every five plan years. The record shows that the enrollee received a crown (D2751)
on tooth #7 on February 2, 2016 and the enrollee's crowns, inlays, and onlays benefit is now exhausted.
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #7.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve coronary angiography for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysbased on the clinical information, this 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 the services. Ourreviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has increased coronary risk, atypical symptoms not suggestive of coronary ischemia, no ischemic electrocardiographic changes, normal troponin and no documented ischemia on nuclear stress test (perfusion images not documented). In this setting of atypical symptoms and no documented objective evidence of coronary ischemia the records do not support the medical necessity for coronary angiography. Coverage criteria for angiography are not met since there are no documented covered indications for the procedure. Current guidelines also do not consider coronary angiography appropriate in this setting.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecoronary angiography for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure high protein (B4150).You asked the Plan to pre-approve the ensure high protein. You say that the enrollee was prescribed Ensure high protein due to her diagnosis of protein caloric malnutrition.The Plandenied your request. The Plan says enteral supplements taken orally are not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approveare nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveEnsure high protein (B4150).