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

We decided that the Plan does not have to pre-approve replacement dentures.
You asked the Plan to pre-approve the dental items. You say that you need your dentures to be replaced. You say that the dentures you received 1.5 years ago no longer fit correctly. You say that the original provider will not work with you to fix them. You say they never have open appointments and the repeated visits cause you to miss work. The Plan denied your request. The Plan says dentures are covered once every 60 months. The Plan also says that the frequency limit has been reached.
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 and dentures are listed as a covered service, the frequency limit has been reached. The record shows the Plan paid for dentures that you received on April 26, 2018. Therefore, we decided that the Plan does not have to pre-approve replacement dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider for a kidney transplant evaluation.You asked the Plan to pre-approvethese services. You say that the wait time at the out-of-network provider is shorter.The Plan denied your request. The Plan says the services are available from network providers.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. The file shows that you were approved for a kidney transplant evaluation with a network provider on August 16, 2019.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider for a kidney transplant evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe lumbar sacral orthosis provided on September 30, 2019.You asked the Plan to waive the coinsurance forthe orthosis. You say that you are being over-billed for this item.The Plan denied your request. The Plan says that you are responsible for the cost-sharing.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 10% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 10% coinsurance for the orthosis. The orthosis falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe lumbar sacral orthosis provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for a small bowel obstruction. The enrollee's post-operative course was complicated by pneumonia and respiratory failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator to a tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) and wound debridement
(11042) provided from July 9, 2019 to September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care and wound debridement. You say that these services were
medically necessary. The Plan denied your request. The Plan says these 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 has network providers
available who can provide 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 nursing facility care (99308) and wound
debridement (11042) provided from July 9, 2019 to September 16, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on November 1, 2019.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you previously had one and were not charged this amount. You say that the copayment is too high for you to pay. 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 $325 per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $325 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls 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 copayment for the myocardial perfusion imaging provided on November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical extraction of teeth #2, 5, 6, 7, 11, 13, 21, 26, and 27, and the general anesthesia.
You asked the Plan to pre-approve the dental services. You say that you would like to have your teeth extracted. You say that your cardiologist and pulmonologist believe the extractions are medically necessary. You say that you have a severe lung infection and do not have money available to you. The Plan denied your request. The Plan says the extractions and anesthesia are dental in nature. The Plan also says that the services are not related to an injury or radiation therapy.
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. Therefore, we decided that the Plan does not have to pre-approve the surgical extraction of teeth #2, 5, 6, 7, 11, 13, 21, 26, and 27, and the general anesthesia.
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 (L3010). You say that your mobility will be greatly inhibited without the orthotics. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 17, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture with a flexible base (D5225) and a mandibular partial denture with a flexible base (D5226).
You asked the Plan to pre-approve the dental services. You say that the enrollee lost their previous partial dentures. You say they would like to get a new set. You also say that the enrollee would consider either partial dentures with flexible bases or partial dentures with cast metal framework with resin denture bases, which ever can be approved. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says that the frequency limit has been reached. The Plan also says that regardless of the codes being requested, the current codes being requested have already been provided less than 5 years ago.
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 and partial dentures are a covered service, the frequency limit has been reached. The record shows the Plan paid for a maxillary partial denture that the enrollee received on December 27, 2018 and a mandibular partial denture that the enrollee received on January 2, 2019. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture with a flexible base (D5225) and a mandibular partial denture with a flexible base (D5226).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cyst removal you had on August 2, 2019.You asked the Plan to pay forthe cyst removal. The Plan denied your request. The Plan says cosmetic procedure are not covered.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  We looked at the file and Medicare rules. The requested procedure was cosmetic in nature, as it was not required for the prompt repair of accidental injury or to improve the functioning of a malformed body member.Based on this information, we decided that Medicare rules for coverage of the cyst removal have not been met.Therefore, we decided that the Plan does not have to pay forthe cyst removal you had on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea resin-based composite on tooth #15.You asked the Plan to pre-approvethe resin-based composite. You say that the enrollee feels a hole on his upper left side. You also say that food gets stuck and the enrollee feels discomfort.The Plandenied your request. The Plan says this service exceeds the benefit allowance.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 applyin this case.Though the Plan offers a dental benefit in excess of Medicare coverage, restorative services are limited to one restoration per tooth every 36 months. The record shows that the enrollee received a resin-based composite on tooth #15 on January 1, 2018 and the enrollee's amalgam or resin restorative benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea resin-based composite on tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus capsules at a lower cost (tier exception).
You asked the Plan to pre-approve Tacrolimus capsules at a lower cost (tier exception). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says tier exceptions only apply to Part D drugs.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs provided in-network. We looked at the file, the Plan's contract and Medicare rules. In this case, you are requesting a tier exception for Tacrolimus capsules. Medicare says that tier exceptions only apply to Part D drugs. Under Medicare rules, your request is not covered for a tier exception because Tacrolimus capsules are not covered under Medicare Part D. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus capsules at a lower cost (tier exception).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (destruction of intraosseous
basivertebral nerve)
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says this is experimental, and has not been proven to safe and effective for this
diagnosis.
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 procedure. Our reviewer says that
the requested procedure is not considered medically reasonable and necessary in this case. Our physician
reviewer found this is considered experimental. More research is needed to show safety and efficacy.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure (destruction of intraosseous basivertebral nerve)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October
14, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you have this bloodwork
every year and never had a copayment. 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 $15
copayment for each in-network covered lab service.
You have been asked to pay a $15 copayment for laboratory services. Laboratory services 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 copayment for laboratory services provided on October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea gait belt.You asked the Plan to pre-approvea gait belt. You say that the gait belt is to prevent the enrollee from having a catastrophic fall. The Plan denied your request. The Plan says a gait belt is not considered medical equipment.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a gait belt have not been met.Therefore, we decided that the Plan does not have to pre-approvea gait belt.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two first intraoral periapical x-rays, two additional intraoral periapical x-rays, resin-based composite, problem focused limited oral evaluation, and extraction provided from September 12, 2019 to November 19, 2019.
You asked the Plan to pay for the intraoral periapical x-rays, resin-based composite, and extraction. You say that a Plan representative said that your dental plan covered preventive measures beginning January 2019. You also say that fillings should be considered preventive measures. The Plan denied your request. The Plan says these 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two first intraoral periapical x-rays, two additional intraoral periapical x-rays, resin-based composite, problem focused limited oral evaluation, and extraction provided from September 12, 2019 to November 19, 2019.
Your complaint about being given misinformation about the Plan you originally signed up for 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 14, 2019.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for spirometric recording (94016) provided on September 21, 2019.
You asked the Plan to pay for the spirometric recording. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 94016 is a non-covered service per Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 94016 is patient-initiated spirometric recording per 30-day period of time; review and interpretation only by a physician or other qualified health care professional. We find that CPT code 94016 is not supported in the record. Specifically, per Local Coverage Determination (LCD): Non-covered Services (L33629), this service is non-covered. Based on this information, we decided that Medicare rules for coverage of the spirometric recording have not been met. Therefore, we decided that the Plan does not have to pay for spirometric recording (94016) provided on September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 to
November 22, 2019 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 a non-participating 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 has network providers
available who can provide 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 medical services provided on November 19,
2019 to November 22, 2019 by an out of network (OON) provider.