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

We decided that the Plan does not have to pay for the hearing aids provided on May 14, 2019.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says these hearing aids are not covered.
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.
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. The hearing aids rendered on May 14, 2019 do not fall under
the copayment structure per your EOC. In addition, you were advised by the provider that the model of hearing
aids that was purchased did not fall under the copayment structure. Therefore, we decided that the Plan does
not have to pay for the hearing aids provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics (code D6240) for tooth #'s 28 and 5 and retainer crowns (code D6750) on tooth #'s 27, 29, 6, and 7 provided on June 4, 2019 and July 22, 2019.
You asked the Plan to pay for the pontics and retainer crowns. You say that you needed to replace your extracted teeth with pontics and new crowns because the partial did not work. You also say that these services gave you stronger teeth. The Plan denied your request. The Plan says the dentist's notes/x-rays do not show a lost tooth in a full arch and the replacement tooth has opposing teeth in the arch.
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 pontics and retainer crowns 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 pay for the pontics and retainer crowns. Our reviewer says that the services were not medically necessary. Our physician reviewer found there are multiple missing posterior teeth. Our reviewer found that the bridge placements were new and not a replacement and included a cantilever pontic on the upper arch adding a tooth to the arch. Our physician reviewer found that the provided x-rays are not sufficiently clear to assess the stability of the abutments for the bridges, however plan limitations would determine coverage issues regardless of the suitability of the teeth to support the bridgework.
Our reviewer also found that given the criteria of allowing only for replacement of existing bridges in cases where there is only one missing tooth in an arch, there is no finding of medical necessity as multiple teeth are missing from both arches. 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 pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pay for the pontics (code D6240) for tooth #'s 28 and 5 and retainer crowns (code D6750) on tooth #'s 27, 29, 6, and 7 provided on June 4, 2019 and July 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by a
non-contracted 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-contracted 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 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 September 6,
2019 by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on August 22, 2019.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 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 rules. The requested provider in this case is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown, porcelain fused to high noble metal tooth/area -
26, 11, 10, endodontic therapy, anterior tooth (excluding final restoration) - tooth area - 11, 26, and
prefabricated post and core in addition to crown - tooth/area: 26 and 11.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says the Plan rules have not met.
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 dental
services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Inhibiting a poor prognosis due to gross carious destruction
of the clinical crown at/or below the bone level, advanced periodontal disease, untreated periapical pathology
or poor restorability are not covered. The clinical shows teeth #10 and #11 have severe periodontal disease and
both evident of decay at or below the bone level. These requirements have not been met and therefore applying
a crown to this tooth is not reasonable or necessary. Because the request for a crown for tooth #10 is considered
not medically necessary, the request for a core buildup to support a crown is not medically necessary. There are
other treatments for this tooth which may be medically appropriate or necessary. You have other options to
replace these teeth which will have long-term viability. Therefore, we decided that the Plan does not have to
pre-approve crown, porcelain fused to high noble metal tooth/area - 26, 11, 10, endodontic therapy, anterior
tooth (excluding final restoration) - tooth area - 11, 26, and prefabricated post and core in addition to crown -
tooth/area: 26 and 11.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 3, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the medical eye exam provided on January 30, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that there should not have been copayment because your wife had the same procedure with the same plan and was not charged a copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees pay nothing for Medicare-covered services and for up to one routine eye examination every year. The Plan says you must pay a $10 copayment for the medical eye exam. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the medical eye exam. The record shows you were billed for a medical eye exam due to diabetes and early cataract diagnoses. Therefore, we decided that the Plan has to waive the copayment for the medical eye exam provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglass lenses.
You asked the Plan to pre-approve eyeglass lenses. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exhausted your allowable benefit for eyeglass lenses. You will be eligible for new lenses as of November 7, 2020.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear 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 rules. Based on this information, we decided that the Plan's rules for coverage of eyeglass lenses have not been met. Specifically, you previously received lenses on November 7, 2018. The Plan benefit allows for $200 towards the purchase of routine eyewear every two years. Therefore, we decided that the Plan does not have to pre-approve eyeglass lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits, testing and therapy to be provided by a naturopath.
You asked the Plan to pre-approve the naturopath services. You say that you would like reconsideration because the services of this provider have been beneficial for your health. The Plan denied your request. The Plan says the care that you are requesting is considered to be a naturopathic service and therefore is an excluded service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pre-approve office visits, testing and therapy to be provided by a naturopath.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve genetic testing. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this
provider is out-of-network with the Plan and these tests can be performed within the Plan network.
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
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit (K0108) folding adjustable angle and height seat back (K0108) integrated fold down push handles (K0108)  lite speed billet aluminum wheels (K0108) aluminum rigid removable standard side guards (K0108).You asked the Plan to pre-approve the other wheelchair accessories. You say that you are requesting an appeal and have attached additional clinical information from the therapist and doctor along with the original medical documentation that was submitted.The Plan denied your request. The Plan says the seat back, folding push handles and side guards do not serve a medical purpose.  The transit Kit and special wheels are items for use outside of the home. Items intended for use outside the home (different surfaces) are not DME and cannot be covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  Medicare rules say that items and services that are not medically necessary are not covered.The items at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are a convenience items  and/or  are 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-approve a transit kit (K0108) folding adjustable angle and height seat back (K0108) integrated fold down push handles (K0108)  lite speed billet aluminum wheels (K0108) aluminum rigid removable standard side guards (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topreapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical interspinous fixation with decompression (Coflex). You asked the Plan to pre-approve Coflex procedure. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Coflex is considered investigational and 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 Coflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and there is no spinal instability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Coflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve surgical interspinous fixation with decompression (Coflex)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95810).
You asked the Plan to pre-approve a sleep study. You say that this is necessary for the enrollee's sleep apnea. The Plan denied your request. The Plan says this service is included in the approved code 95811.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that 95810 has a Column One/Column Two relationship with code 95811. This code cannot be paid as a separate line item. The services represented by code 95810 are included in 95811 and cannot be separately approved. Therefore, we decided that the Plan does not have to pre-approve a sleep study (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair and accessories.You asked the Plan to pre-approvea Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair and accessories.The Plan denied your request. The Plan says Medicare does not provide durable medical equipment in a nursing facility.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF.Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve joint aspiration (20606).
You asked the Plan to pre-approve joint aspiration. You say that this treatment has improved the enrollee's pain. The Plan denied your request. The Plan says the records do not show this is 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 joint aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the existing medical records do not support the need for joint injection of aspiration. More documentation is needed to show the diagnosis and previous attempts at treatment. Not enough evidence is present in the records to support this intervention 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 joint aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve joint aspiration (20606).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone 25MG/2.5 G Pkt.
You asked the Plan to pre-approve Testosterone (J3490). You say that you want to be treated with this drug. The Plan denied your request. The Plan says this drug is not a Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Testosterone 25MG/2.5 G Pkt.
Benefits for Testosterone (J3490) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Epoetin Alfa.
You asked the Plan to pre-approve Epoetin Alfa. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the records do not show that the enrollee has a condition for which Epoetin Alfa is used.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Epoetin Alfa. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Epoetin Alfa. Our physician reviewer found the enrollee has a diagnosis of aplastic anemia. Medicare-approved drug compendia do not support the use of Epoetin Alfa for this diagnosis. Therefore, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epoetin Alfa have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Epoetin Alfa.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria because she is at a functioning level where her therapy needs can safely be met at a lower level of care in a subacute nursing facility. 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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but, based on the medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 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.