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

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and mandibular partial denture (D5212).
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you are not able to chew which is causing health issues for you. The Plan denied your request. The Plan says these services exceed 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, complete maxillary denture and mandibular partial denture are each limited to one procedure every five plan years. The record shows that you received a mandibular partial denture on January 28, 2016, and a complete maxillary denture on December 21, 2017 and your complete maxillary denture and mandibular partial denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and mandibular partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prefabricated post and core, in addition to crown (D2954) provided November 21, 2019 to November 27, 2019.
You asked the Plan to pay for the dental services. You say that you do not believe your father should be responsible since he was never made aware of the total and was only asked for $150 which he paid. The Plan denied your request. The Plan says this service is not covered under the plan 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 covered under this benefit. Therefore, we decided that the Plan does not have to pay for prefabricated post and core, in addition to crown (D2954) provided November 21, 2019 to November 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home visit for venipuncture (blood draw).You asked the Plan to pre-approveblood draw home visit. You say that you need your blood drawn regularly due to your condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because home health is not covered by Medicare solely for the purposes of venipuncture (blood draw).The Plan must follow Medicare rules. Medicare rules say that home health is not covered by Medicare when provided solely for the purposes of venipuncture (blood draw). We looked at the file and Medicare rules. This home health visit is being requested solely for the purposes of performing a blood draw. Based on this information, we decided that Medicare rules for coverage of blood draw home visit have not been met.Therefore, we decided that the Plan does not have to pre-approveahome visit for venipuncture (blood draw).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gel arm pads and wheelchair power seat elevation.
You asked the Plan to pre-approve gel arm pads and wheelchair power seat elevation. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested items are not covered benefits.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Also, the rules say that a power seat elevation feature is non-covered. The gel arm pads 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. In addition, the power seat elevation feature is non-covered. Therefore, we decided that the Plan does not have to pre-approve gel arm pads and wheelchair power seat elevation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on January 14, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says you must use a doctor in the hearing network for services to be 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. The hearing aids were provided by a non-contract provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide transmitter and sensors for a non-therapeutic continuous glucose monitor.
You asked the Plan to provide the transmitter and sensors. You say that you say you need a replacement CGM and sensors. The Plan denied your request. The Plan says this is considered to be a non-therapeutic CGM device per Medicare guidelines and is therefore non-covered.
The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor. In this case, the CPT Code Manual definition of code A9276 is Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system. We find that CPT code A9276 is not covered by Medicare. Therefore, we decided that the Plan does not have to provide transmitter and sensors for a non-therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion/pillow/wedge.
You asked the Plan to pre-approve a positioning cushion/pillow/wedge. You say that you need a positioning
cushion to sleep at night. The Plan denied your request. The Plan says positioning cushions do not serve a
medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a positioning cushion/pillow/wedge.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services on an inpatient basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, his lungs were clear, and he was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a close supervision level of functional mobility. He required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on March 2, 2020.You asked the Plan to pay forthe periodontal maintenance. You say that this service was referred to as a basic cleaning by the provider's office. You also say that this cleaning, as well as others, are always basically the same.The Plan denied your request. The Plan says this 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 pay forthe periodontal maintenance provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve accessory carrying case (E2599) and protective case or
cover, any type (E2599).
You asked the Plan to pre-approve the accessory carrying case and protective cover. You say that suffering
from aphasia is a life changing event that has left the enrollee with an inability to communicate the most
necessary things. The Plan denied your request. The Plan says an accessary carrying case is a convenience item
and therefore non-covered. The protective case is not separately payable as the is included (bundled) with the
SGD and required to make the SGD durable under the definition of DME.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The protective case is included with the SGD. The accessory carrying case 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-approve accessory carrying
case (E2599) and protective case or cover, any type (E2599).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power seat elevation system (E2300), an expandable controller (E2377), and a harness (E2313) provided on September 25, 2019.
You asked the Plan to pay for a power seat elevation system, an expandable controller, and a harness. You say that these items are necessary for his wheelchair to function. The Plan denied your request. The Plan says these items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically necessary according to the above guidelines. A power seat elevation feature is non-covered because it is not primarily medical in nature. 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 a power seat elevation system, an expandable controller, and a harness. Our reviewer says that the criteria for coverage have not been met for the items at issue. Our physician reviewer found the limited documentation does not demonstrate that an expandable controller was medically necessary for any of the items listed above. Therefore, the harness is also not covered. The power seat elevation system is excluded from coverage. The record shows that notice of non-coverage was given prior to the date 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 a power seat elevation system, an expandable controller, and a harness have not been met. Therefore, we decided that the Plan does not have to pay for a power seat elevation system (E2300), an expandable controller (E2377), and a harness (E2313) provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve premolar tooth endodontic therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says the codes requested by the provider are not the codes covered per the supplemental
dental coverage.
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-approve
premolar tooth endodontic therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection.
You asked the Plan to pre-approve Synvisc. You say that the enrollee has osteoarthritis in her left hand. The Plan denied your request. The Plan says medical studies have not proven Synvisc helpful in joints other than the knee.
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 pre-approve Synvisc. Our physician reviewer found that the enrollee has unilateral primary osteoarthritis of first carpometacarpal joint of the left hand. Purified natural hyaluronans have been approved by the FDA for the treatment of pain associated with osteoarthritis of the knee. The requested use of Synvisc is not FDA-approved for the enrollee's diagnosis. The use of Synvisc in this clinical setting is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested service is not medically reasonable and 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the enclosed walker.
You asked the Plan to pre-approve a walker, enclosed, four sided framed, rigid or folding, wheeled with
posterior seat (E0144). You say that the enrollee has a gait dysfunction and needs a walker. The Plan denied
your request. The Plan says the requested walker is statutorily not covered by Medicare.
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. Medicare does not cover a walker, enclosed, four sided framed, rigid
or folding, wheeled with posterior seat (E0144). Therefore, we decided that the Plan does not have to preapprove
the enclosed walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) periodontal maintenance (D4910) intraoral-periapical first x-ray (D0220) provided February 28, 2020.
You asked the Plan to pay for the dental services. You say that this visit was for a cleaning and x-rays. According to your understanding of your benefits, two cleanings and x-rays are covered under the dental portion of your plan per year. The Plan denied your request. The Plan says these services are not covered under the plan 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 covered under this benefit. Therefore, we decided that the Plan does not have to pay for limited oral exam (D0140) periodontal maintenance (D4910) intraoral-periapical first x-ray (D0220) provided February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe wheelchair provided on February 26, 2020.You asked the Plan to waive the coinsurance forthe wheelchair. You say that the wheelchair was supposed to be picked up May 2019.The Plan denied your request. The Plan says the supplier has no record of your pickup request so you were charged this coinsurance 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the wheelchair. the wheelchair falls within the durable medical equipment and related supplies 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 coinsurance forthe wheelchair provided on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 24, 2019, to May 25, 2019.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was hemodynamically stable. There was no indication for admission. The enrollee should have been put in observation and admitted only if unstable based on a number of factors such as low blood pressure, increased heart rate, persistent bleeding, or falling hemoglobin.
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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 24, 2019, to May 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that because of leg length discrepancy you need shoes and inserts 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 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-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns provided on March 16, 2020.
You asked the Plan to pay for the crowns. You say that prior to your appointment, you called the Plan and were told crowns were covered. The Plan denied your request. The Plan says this service is 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two crowns provided on March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 22, 2019.You asked the Plan to pay forthe 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.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plandoes not have to pay forthe laboratory services provided on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance forthe infusion set for external insulin pump, supplies for external insulin infusion pump and external ambulatory infusion pump provided on January 31, 2020.You asked the Plan to waive the coinsurance forthese items. You say that you were told there would be no cost.The Plan denied your request. The Plan says that your benefit was 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for these items. These items fall within the durable medical equipment (DME) and related supplies 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe infusion set for external insulin pump, supplies for external insulin infusion pump and external ambulatory infusion pump provided on January 31, 2020.