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

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).

You asked the Plan to pre-approve the occlusal guard. You say that you would like the occlusal guard to be considered for coverage under your preventive dental services benefit of your insurance coverage. The Plan denied your request. The Plan says this service is 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 pre-approve an occlusal guard (D9944).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 you have lumbar spinal stenosis. The requested Superion spacer is experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 9, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that your dentist recommended you receive the extraction from an oral surgeon. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on February 23, 2021 and your problem focused limited oral
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second set of diagnostic medial branch blocks for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not indicated at this time.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD requires 80% or greater pain relief to be considered positive. The enrollee underwent a first set of diagnostic injections and achieved 25% pain relief for six hours. This set of blocks should be considered as negative, and another pain generator should be sought. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a second set of diagnostic medial branch blocks for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pulmonary function testing provided on February 23, 2021.
You asked the Plan to waive the copayment for pulmonary function testing. You say that you were not aware that you would owe such a high copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $195 copayment for services furnished at a hospital outpatient facility for outpatient hospital services. The record shows that you received pulmonary function testing on February 23, 2021 at an outpatient hospital facility. Therefore, you are responsible to pay the $195 copayment.
You have been asked to pay a $195 copayment for pulmonary function testing. Pulmonary function testing falls within the outpatient hospital 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 pulmonary function testing provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve angioplasty services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee's symptoms are manageable if treated within a reasonable timeframe. The Plan denied your request. The Plan says there are in-network providers that can provide this service.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve angioplasty 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 power seat elevation system.

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 covered.

The Plan must follow Medicare rules. The rules say that a power seat elevation system is non-covered. 

We looked at the file and Medicare rules. The services at issue are a power seat elevation system. These services are not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 3, 2021.

You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you are contractually obligated to pay for the services rendered by a provider that doesn't participate with Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four restorative procedures (D2999 x4), two periodontal procedures (D4999 x2), and two implant procedures (D6199 x2).

You asked the Plan to pre-approve the restorative procedures, periodontal procedures, and implant procedures. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit package.

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 four restorative procedures (D2999 x4), two periodontal procedures (D4999 x2), and two implant procedures (D6199 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010 x4), guided tissue regeneration (D4266), bone replacement graft (D7953), connecting bar (D6055), precision attachment (D5862 x2), and prefabricated abutment (D6056 x4).
You asked the Plan to pre-approve surgical placement of implant body, guided tissue regeneration, bone replacement graft, connecting bar, precision attachment, and prefabricated abutment. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010 x4), guided tissue regeneration (D4266), bone replacement graft (D7953), connecting bar (D6055), precision attachment (D5862 x2), and prefabricated abutment (D6056 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249).
You asked the Plan to pre-approve clinical crown lengthening. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the service at issue it not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve clinical crown lengthening (D4249).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed prior to treatment with Euflexxa. The documentation does not outline contraindications or reasons Orthovisc and Monovisc were not considered or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.
You asked the Plan to pre-approve the requested gloves. You say that changing your ileostomy without gloves is unsanitary. The Plan denied your request. The Plan says the gloves are non-reusable and not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The gloves at issue in this appeal does not serve a purpose that is primarily medical in nature. The items 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 non-sterile gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the disposable medical examination gloves provided from May 18, 2020 to November 20, 2020.

You asked the Plan to pay for the disposable medical examination gloves. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that the gloves are not covered by Medicare or the Plan.

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 pay for the disposable medical examination gloves provided from May 18, 2020 to November 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, abdomen and pelvis.
You asked the Plan to pre-approve computed tomography, abdomen and pelvis; without contrast material (74176). You say that the enrollee needs an abdominal and pelvic CT. The Plan denied your request. The Plan says clinical documentation submitted reveals the enrollee's lab tests and ultrasound are within normal limits and pain is improving.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 computed tomography, abdomen and pelvis; without contrast material (74176). Our reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee complains of abdominal bloating. Physical examination reveals epigastric mild tenderness. Laboratory studies and ultrasound are normal except for surgically absent gallbladder. The medical records submitted so not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of computed tomography, abdomen and pelvis; without contrast material (74176) have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, abdomen and pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 24, 2021.
You asked the Plan to waive the copayment for the office visit. You say that your mother was very unhappy with the service that was provided, and she shouldn't be responsible for the copayment. You say that the provider should refund it back. The Plan denied your request. The Plan says the copayment 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 $35 copayment for medical care or surgery services in a specialty physician's office.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on February 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says there are no suspicious lesions or abnormal symptoms.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT scan. Our physician reviewer found that in this case, the record indicates that the enrollee has bronchiectasis, chronic obstructive pulmonary disease, and common variable immunodeficiency. The records indicate that she was last seen in November 2020 and was stable without issue. A CT scan was requested for six months later. The medical records do not support the medical necessity and reasonableness of the requested 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 25, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this provider is not a network provider and in-network providers were available.

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 had network providers available who could have provided 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 laboratory services provided by an out-of-network provider on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperthermia treatment (77605).
You asked the Plan to pre-approve hyperthermia treatment. You say that this requested treatment is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that local hyperthermia is covered under Medicare when used in connection with radiation therapy for the treatment of primary or metastatic cutaneous or subcutaneous superficial malignancies. 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 hyperthermia treatment. Our reviewer says that the requested criteria for coverage of the hyperthermia treatments have not been met. Our physician reviewer found the patient is a 62-year-old male with diagnosed thymoma recurrent or metastatic disease extending to the pleural cavity status post radiation therapy, resection, chemotherapy with recent recurrence. Hyperthermia treatment was requested in addition to planned cytoreductive surgery with pleurectomy with hyperthermic intrathoracic chemotherapy. The NCD states that local hyperthermia is not covered when used alone or with chemotherapy.
The National Comprehensive Cancer Network Guidelines does not list hyperthermia as a covered treatment in this clinical situation. Based on the provided documentation, there were no plans for radiation therapy; therefore, the NCD criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperthermia treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperthermia treatment (77605).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vitrectomy chair.
You asked the Plan to pre-approve the requested chair. The Plan denied your request. The Plan says Medicare does not cover this item.
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. Therefore, we decided that the Plan does not have to pre-approve a vitrectomy chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator with non-invasive interface (E0644).

You asked the Plan to pre-approve the home ventilator. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee does not meet coverage for a ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 home ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee may benefit from nocturnal BiPAP, but Medicare does not pay for a ventilator when used as BiPAP. There is no evidence of BiPAP failure. The denial of the ventilator is upheld. 

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator with non-invasive interface (E0644).