Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual therapy services (97140) to be provided by a chiropractor.
You asked the Plan to pre-approve manual therapy services. You say that the need for this service is supported in the records. The Plan denied your request. The Plan says this is not a covered chiropractic service.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve manual therapy services (97140) to be provided by a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with codes D7140, D7210, D5211, and
D5212.

You asked the Plan to pre-approve dental codes D7140, D7210, D5211, and D5212. You say that you are
having a lot of tooth pain and you need the services requested. The Plan denied your request. The Plan says the
dental codes requested are not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, 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
dental services with codes D7140, D7210, D5211, and D5212.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on January 22, 2021.

You asked the Plan to waive the copayment for an eye exam. You say that your insurance says that you should only owe a $25 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 $25 copayment for eye exams provided by a primary care physician and a $35 copayment when provided by a specialist. 

The record shows that you received an eye exam on January 22, 2021, by an optometrist. An Optometrist is considered a specialist. Therefore, you are responsible to pay the $35 copayment. 

You have been asked to pay a $35 copayment for an eye exam. An eye exam falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) and the alveoloplasty not in conjunction with extractions (D7321) provided on February 9, 2021.

You asked the Plan to pay for the dental services. You say that you believe that these services should be covered. You say that you received these services under a different plan, and they were covered. You also say that you do not understand why they are not covered now. The Plan denied your request. The Plan says extraction is not listed as a covered service. The Plan says that alveoloplasty not in conjunction with an extraction is not listed and therefore is not a covered service either.

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 extraction (D7210) and the alveoloplasty not in conjunction with extractions (D7321) provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1110, D0150, D0274) received February 9, 2021.

You asked the Plan to pay for the dental services (D1110, D0150, D0274). You say that you moved to a new area and wanted to establish as a new patient with the dentist. The Plan denied your request. The Plan says you do not have a supplemental benefit that covers preventive dental services.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services (D1110, D0150, D0274) received February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar, for use in shower or bathtub.

You asked the Plan to pre-approve a grab bar. You say that your physician has prescribed a bar for safety and fall prevention. You have been struggling with arthritis, which is easier by a bath, yet the transfer is not safe. 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 grab bars are not covered because they are not primarily medical in nature. 

While a grab bar 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 grab bar, for use in shower or bathtub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have been diagnosed with neuropathy which primarily affects your feet and ankles. Please reconsider the decision to deny coverage for custom orthotics. The Plan denied your request. The Plan says this enrollee does not meet the criteria for coverage of the requested item.

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 custom foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve these services. You say that you need the equipment so you can travel home from Texas. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and the crown - porcelain/ceramic (D2740) provided December 8, 2020.

You asked the Plan to pay for the intraoral x-rays and crown. You say that your contract does not require you to see a network provider and previous services from this provider have been covered in the past. The Plan
denied your request. The Plan says the provider who rendered the services has opted-out of Medicare and therefore the services are 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. The Plan covers the intraoral x-rays and crown when provided by a licensed dental provider who accepts Medicare patients and has not opted out of Original Medicare. 

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the intraoral x-rays and crown have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and the crown - porcelain/ceramic (D2740) provided December 8, 2020.

Your complaint about the Plan potentially providing coverage for services from this provider in the past is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient psychotherapeutic services to be provided by an out of network provider.
You asked the Plan to pre-approve outpatient psychotherapy. You say that Plan providers only want to increase your medication without a reason and are tremendously uncaring. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 services. Therefore, we decided that the Plan does not have to pre-approve outpatient psychotherapeutic services to be provided by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hernia repair surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve surgery services. You say that no one else in the enrollee's network provides these services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
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 hernia repair surgery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on November 23, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $50 copayment for each in-network specialist visit for Medicare-covered services.

Review of the file shows that you received specialist services on November 23, 2020. You have been asked to pay a $50 copayment for these services. These services fall within the in-network specialist visit for Medicare-covered 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 the specialist services rendered on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the heavy-duty walker provided on February 12, 2021 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 an out-of-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 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 the heavy-duty walker provided on February 12, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140) received February 9, 2021 from the non-participating provider.

You asked the Plan to pay for the extraction. You say that you had a toothache and did not have time to find who is in network. The Plan denied your request. The Plan says services are only covered when received by a participating provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

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. The Plan contract clearly states that services are only covered when received by a participating provider. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140) received February 9, 2021 from the non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest (71260) and CT scan of the
abdomen and pelvis (74177).

You asked the Plan to pre-approve a CT scan of the chest (71260) and CT scan of the abdomen and pelvis
(74177). You say that the requested CT scan of the chest (71260) and CT scan of the abdomen and pelvis
(74177) are medically necessary. The Plan denied your request. The Plan says the requested CT scan of the
chest (71260) and CT scan of the abdomen and pelvis (74177) are not medically necessary.

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 a CT scan of the chest (71260) and CT
scan of the abdomen and pelvis (74177). Our reviewer says that the requested CT scan of the chest (71260) and
CT scan of the abdomen and pelvis (74177) are not medically necessary. Our physician reviewer found
unintentional weight loss is considered significant if greater than 5% of usual body weight over 6-12 months.

This enrollee is documented as having lost "a few pounds." No work-up other than laboratory have been
pursued. A CT scan is reserved if blood work, chest x-ray, and age-appropriate cancer screening have been
done. There is no documentation that this has been completed or that there were other specific symptoms for
which imaging with CT would be indicated. CT scans are 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 a CT scan of the chest (71260) and CT scan of the abdomen and pelvis (74177)
have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest
(71260) and CT scan of the abdomen and pelvis (74177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2025, V2781, V2750) purchased on December 30, 2020, from an out-of-network retailer.

You asked the Plan to pay for the eyeglasses. You say that you purchased glasses from this same retailer in 2019 and the glasses were covered at that time. You feel this pair should be covered as well. The Plan denied your request. The Plan says routine vision services received outside of the Plan's specified routine vision provider network are not covered.

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. The Plan covers up to $100 for eyeglasses when they are purchased from a provider within the Plan's specified routine vision network. Routine eyewear received out-of-network is not covered.

We looked at the file and the Plan's rules. The eyeglasses were purchased out-of-network. 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 pay for the eyeglasses (V2025, V2781, V2750) purchased on December 30, 2020, from an out-of-network retailer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248).

You asked the Plan to pre-approve non-intravenous conscious sedation. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by the Plan's dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, 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 non-intravenous conscious sedation (D9248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant. You say that you cannot speak properly due to the movement of your dentures. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 the surgical placement of implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a post and core in addition to crown (D2952).

You asked the Plan to pre-approve the post and core. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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, 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 a post and core in addition to crown (D2952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7952) for tooth 19.

You asked the Plan to pre-approve a bone replacement graft. You say that this service is medically necessary to treat bone loss and prevent additional damage. 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 pre-approve a bone replacement graft for ridge preservation (D7952) for tooth 19.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulsed radiofrequency ablation (RFA) of the genicular nerves.

You asked the Plan to pre-approve pulsed radiofrequency ablation of the genicular nerves. You say that the pulsed radiofrequency ablation of the genicular nerves is medically necessary. The Plan denied your request. The Plan says the pulsed radiofrequency ablation of the genicular nerves 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 pulsed radiofrequency ablation of the genicular nerves. Our reviewer says that the pulsed radiofrequency ablation of the genicular nerves is not medically necessary. Our physician reviewer found the enrollee has chronic right knee pain due to osteoarthritis and a complex meniscus tear. She has tried a brace, heat, ice, TENS, Tylenol, Ibuprofen, topical Voltaren, as well as Physical Therapy and viscosupplementation. She had diagnostic genicular blocks which gave significant pain relief. The request is for Pulsed RFA of the genicular nerves. 

Pulsed RFA is considered experimental/investigational by Medicare. RFA of the genicular nerves is considered experimental/investigational and is the subject of on-going clinical trials to determine its role in the management of knee osteoarthritis. Therefore, the request is deemed not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pulsed radiofrequency ablation of the genicular nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve pulsed radiofrequency ablation (RFA) of the genicular nerves.