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

We decided that the Plan does not have to pre-approve dental extractions under your medical insurance.
You asked the Plan to pre-approve the extractions under your medical insurance. You say that you need the
extractions to be approved for coverage. The Plan denied your request. The Plan says the documentation fails
to indicate that the requested dental extraction is medically necessary.
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
able to be covered under your medical insurance. Your contract with the Plan covers up to $2,500 worth of
comprehensive services, including extractions, each year. You are also responsible for a 50% coinsurance for
extractions provided in-network. There are no medical records provided showing that these extractions are
medically necessary. Therefore, we decided that the Plan does not have to pre-approve dental extractions under
your medical insurance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided August 12, 2020.
You asked the Plan to pay for the orthoses. You say that please review documentation and process the claim for payment as the enrollee is using braces and they are helping her with her issues. The Plan denied your request.
The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician and the documentation submitted did not support the medical necessity of the billed supply code.
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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5225).
You asked the Plan to pre-approve an upper partial denture. You say that you want the Plan to cover the service. The Plan denied your request. The Plan says the service at issue 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 pre-approve an upper partial denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
You asked the Plan to pre-approve the dentures. You say that you were told by a customer service representative that this provider is in-network. The Plan denied your request. The Plan says this provider is out-of-network, and services obtained outside of the dental vendor network will not be 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 only covers supplemental dental services when they are obtained from a provider in the Plan's dental vendor network. Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network items and services are not covered under this benefit. The Plan provided documentation, including a provider directory, that shows that the provider in question does not participate in the Plan's network. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower denture (D5214).
Your complaint about potential misinformation from the Plan or customer service 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency department services provided on March 17, 2020, through March 22, 2020.
You asked the Plan to waive the copayment for the emergency room services. You say that you would like reconsideration because you were told that you do not have to pay this bill. The Plan denied your request. The Plan says the provider is billing you the correct copayment with no other charges.
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 $90 copayment for Emergency Care.
You have been asked to pay a $90 copayment for the emergency room services. The Emergency Department services fall within the Emergency 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. Please note, the Plan has confirmed that the provider has agreed to not bill you for additional charges. If you are being billed for services beyond your $90 copayment, please contact the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency department services provided on March 17, 2020, through March 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 9, 2021.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at an alternate level of care.
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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continued skilled nursing facility services for the enrollee beyond November 30, 2020.
You asked the Plan to provide coverage for continued SNF services. You say that continued services were medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee had exhausted the 100-day benefit and was actually given an extension for a total of 114 days.The QIC overturned the Plans denial stating the case file was lacking records to show the 100 days were exhausted. The Plan requested a reopen and provided the information lacking in the original file.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The records provided show as of November 30, 2020, the enrollee had been provided with coverage for 114 days of a type of inpatient or SNF care, which is more than the amount typically covered by Medicare.
Although the enrollee may have still required skilled care, the Plan is not required to pay for more than 100 days of SNF coverage. Therefore, we decided that the Plan does not have to provide coverage for continued skilled nursing facility services for the enrollee beyond November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture services.
You asked the Plan to pre-approve additional acupuncture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your benefit limit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan covers 12 acupuncture visits in 90 days. Review of the file shows that you have currently used 11 of the covered 12 visits. The plan has noted that they will cover one of the requested four additional visits for a total of 12 visits per 90 days. The additional three visits exceed your benefit limit. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a sensor (A9276) and a transmitter (A9277) for a continuous glucose monitor.
You asked the Plan to pay for the items. You say that this is medically necessary. The Plan denied your request. The Plan says there is no coverage for these items.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that HCPCS A9276 and A9277 are not covered codes. The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pay for a sensor (A9276) and a transmitter (A9277) for a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for diagnostic mammograms provided on December 29, 2020.
You asked the Plan to waive the copayments for diagnostic mammograms. You say that you disagree with the charges. 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 $20 copayment for most x-rays and ultrasounds. The medical records show that you received two diagnostic mammograms on December 29, 2020. Therefore, you are responsible to pay a $20 copayment per each mammogram. The total amount you owe is: $40. You have been asked to pay the total copayment amount of $40 for diagnostic mammograms. Diagnostic mammograms fall within the outpatient diagnostic tests and therapeutic services and 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 copayments for diagnostic mammograms provided on December 29, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Brovana.
You asked the Plan to pre-approve Brovana. You say that the requested Brovana is medically necessary. The Plan denied your request. The Plan says that the requested Brovana is not medically necessary.
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 Brovana. Our reviewer says that the requested Brovana is medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease. The medical records provided do not indicate the enrollee has had an acute deterioration of chronic obstructive pulmonary disease at the time the Brovana is being initiated. The elements of the coverage criteria are satisfied. The requested service is 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 Brovana have been met. Therefore, we decided that the Plan has to pre-approve Brovana.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with dental codes D9222 and D9223.
You asked the Plan to pre-approve dental codes D9222 and D9223. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says anesthesia services with dental codes D9222 and D9223 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, dental codes D9222 and D9223 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services with dental codes D9222 and D9223.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre sensor kit.
You asked the Plan to pre-approve a Freestyle Libre sensor kit. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for CGMs have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre sensor kit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
You asked the Plan to pre-approve the Euflexxa injections. You say that Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial of Durolane, Gelsyn-3, and Synvisc are required before alternatives can be considered.
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 the Euflexxa injections. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective 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 the Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT maxillofacial area.
You asked the Plan to pre-approve computed tomography, maxillofacial area; without contrast material (70486). You say that the enrollee needs a maxillofacial CT. The Plan denied your request. The Plan says there is lack of information that would show the need for the maxillofacial CT.
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, maxillofacial area; without contrast material (70486). Our reviewer says that the CT is not medically necessary. Our physician reviewer found the provided documentation did not reveal any abnormal head and neck physical exam findings to support maxillofacial imaging at this time. CT head should suffice for new baseline testing. Therefore, this request for maxillofacial CT will be considered not medically necessary based on the provided documentation.
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, maxillofacial area; without contrast material (70486) have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography CT maxillofacial area.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can continue to receive appropriate intensive rehabilitation services at the inpatient rehab facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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-approve skilled nursing facility (SNF) services.