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

We decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (D5226) to be
provided by the physician.
You asked the Plan to pre-approve the mandibular partial denture. You say that you are requesting
reconsideration because you are having difficulty chewing and you do not want the material that is approved by
the plan. The Plan denied your request. The Plan says this item 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. The health plan contract says
that flexible base materials prosthetics are not covered.
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
mandibular partial denture - flexible base (D5226) to be provided by the physician.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the spinal contents (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary before you have surgery. The Plan denied your request. The Plan says there is no record that you have tried back stretches or participated in physical therapy, chiropractic treatments or a medically directed home exercise program.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found MRIs are a test of choice for patients with prior back surgery, but for uncomplicated low back pain, with radiculopathy. MRIs not recommended until after at least one month conservative therapy. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the spinal contents (72148).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Actemra.
You asked the Plan to pre-approve Actemra. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of its preferred drugs of Remicade, Inflectra, and/or Simponi Aria before it will approve use of Actemra.
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 Actemra. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Actemra. Our physician reviewer found the Plan requires a trial of the drugs Remicade, Inflectra, and/or Simponi Aria before they will approve use of Actemra. The documentation does not show that the enrollee has tried and failed the Plan's preferred drugs, or that these drugs will 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Actemra.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery.You asked the Plan to pre-approve the oral surgery. You say that this issue stems from cancer and cancer treatment, and has caused severe medical issues with multiple areas of your body. You say that it is not just your teeth. You say that other treatments for your body have been covered and that this issue should be considered medical like they were, rather than dental.The Plan denied your request. The Plan says the dental extractions and implants are considered dental procedures. The plan says that these services are excluded from coverage under Medicare rules.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve 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. The services being requested are not among the non-routine dental care that Medicare covers under the medical benefits.Therefore, we decided that the Plan does not have to pre-approve oral surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the enrollee is not safe to return home.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee needs daily physical or occupational therapy. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy.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 care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second opinion office visits and testing to be provided by the out of network provider.
You asked the Plan to pre-approve the second opinion office visits and testing. You say that the requested services are necessary. The Plan denied your request. The Plan says the services you are requesting can be provided by an in-network provider, therefore coverage criteria to be seen by an out-of-network provider has 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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 second opinion office visits and testing to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction of tooth #20 (code D7210).
You asked the Plan to pre-approve the extraction. You say that the enrollee has an infection and crack in the
tooth and has severe pain. You also say that the enrollee needs this tooth extracted as soon as possible. The
Plan denied your request. The Plan says the service is not 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. The Plan covers the extraction
when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the extraction. Our reviewer says that
the service is not medically necessary. Our physician reviewer found extraction (code D7210) is limited to
situations that require removal of bone to allow for removal of the tooth. Our reviewer found that the provided
x-rays reveal a mostly intact tooth #20 with a moderately large existing amalgam restoration. Our physician
reviewer found that it was noted that there was a fracture in the tooth and that the enrollee was in pain. Our
reviewer found that there is no indication that the crown of the tooth will fracture off during a forceps
extraction of this tooth, and no need for bone removal in order to extract the tooth. Our physician reviewer also
found that given the current presentation, there is no clear necessity for the requested procedure code at this
time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the extraction have not been met. Therefore, we decided that the Plan does not
have to pre-approve an extraction of tooth #20 (code D7210).
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 (L3030). You say that because of your foot condition you cannot get shoes off the rack that will fit and therefore the inserts should be covered. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.You asked the Plan to pre-approve a manual wheelchair. You say that you need a manual wheelchair for when your power wheelchair is charging.The Plan denied your request. The Plan says you are using an approved power wheelchair The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have power wheelchair. The power wheelchair serves the same purpose as a manual wheelchair.Medicare only covers one wheelchair at a time. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
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 you have pain and numbness in your feet. You
say that the orthotics will help provide relief. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheeled walker.
You asked the Plan to pre-approve the wheeled walker. You say that you want a walker that can provide you with more stability. The Plan denied your request. The Plan says per doctor's notes, you were approved for a walker on January 30, 2019.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheeled walker have not been met. Per doctor's notes, you were approved for a walker on January 30, 2019. A replacement of equipment/item is medically necessary only if it is at least five years old, if there is change in member's condition, and the current item no longer meets the need of the member. Therefore, we decided that the Plan does not have to pre-approve wheeled walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that transfer to a lower level of care would place the enrollee at a lesser degree of functional recovery. The Plan denied your request. The Plan says the enrollee does not have neurological or ortho issues.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was medically stable with no evidence of need for supervision by an acute rehab physician, or acute rehab nursing care. They may benefit from further physical and occupational therapy, but does not require an intensive therapy program when they can walk 170 feet with contact guard assist. Therefore, an IRF admission is not 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 5, 2019.You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness exam and you should not be responsible for 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 primary care doctor visits. If during the physical exam, you also receive services to treat a medical condition, you will be expected to pay a $20 copayment for the additional services.  The medical records show that medical conditions were reviewed during an annual wellness exam on September 5, 2019. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for an office visit. An 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 an office visit provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99232) provided to the enrollee on July 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were already billed by a provider of the same specialty for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. The records show that E&M services were previously paid for the same date of service, and provided by a provider of the same specialty as the services in question. This means that the E&M services in question are not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99232) provided to the enrollee on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft (D4263) guided tissue regeneration for teeth 2, 12, 15, 18 and 19 (D4266).
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the services because the dental facility is in network and if the plan does not cover he will need to pay $4,8320. 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. The health plan contract says that any procedures not listed under the Description of Benefits will not be covered. 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 bone replacement graft (D4263) guided tissue regeneration for teeth 2, 12, 15, 18 and 19 (D4266).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider, on May 4, 2019 to June 20, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you don't understand why you pay so much for insurance and you still owe this much.The Plan denied your request. The Plan says the correct copayment has been applied.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 $395 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care/out-of-network. You have been asked to pay a $395 copayment per day for days 1-4. There is a $0 copayment for additional days for an inpatient hospital stay. You are being asked to pay $790 ($395 x 2 days = $790) for your inpatient stay from May 4, 2019 to May 6, 2019. You have been asked to pay $1,580 ($395 x 4 days = $1,580) for your inpatient stay from June 10, 2018 to June 20, 2019. The total amount you are being asked to pay is $2,370 ($790 + $1,580 = $2,370). An inpatient hospital stay falls within the inpatient hospital care/out-of-network 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 inpatient hospital stay provided by an out-of-network provider, on May 4, 2019 to June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses .
You asked the Plan to pre-approve the eyeglasses. You say that the Plan denied your request. The Plan says
you have a vision plan for this type of request, for which you just received glasses less than 2 months ago.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every 2 years.
We looked at the file and the Plan's rules. The file shows that Plan covers supplemental eyeglasses every 2
years. 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 pre-approve eyeglasses..
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9343) provided from July 13 2019, to July 26,2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a valid code.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Procedure code S9343is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the services (S9343) provided from July 13 2019, to July 26, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from May 30, 2019 through June 2, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from May 30, 2019 through June 2, 2019.
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.