Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator.
You asked the Plan to pre-approve a neurostimulator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation under specific circumstances.
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 neurostimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence-based indication for a spinal cord stimulation (SCS) trial. The enrollee has two-disc protrusions and an annular tear. There is not a copy of the psychological evaluation. The procedure is 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 a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation provided by an out-of-network provider on March 29, 2021.
You asked the Plan to pay for the physical therapy evaluation. You say that the services were medically necessary, and the level of care was warranted. You say that you disagree with the denial and the claim should be reprocessed. The Plan denied your request. The Plan says out-of-network 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 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 physical therapy evaluation provided by an out-of-network provider on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from November 16, 2020, through April 27, 2021.
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says this provider is not part of the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from November 16, 2020, through April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services (92014) provided on July 28, 2021.
You asked the Plan to pay for the ophthalmology services. You say that the services were medically necessary. The Plan denied your request. The Plan says there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 ophthalmology services (92014) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 7, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 office visit provided on June 7, 2021 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove intermittent limb compression device.
You asked the Plan to preapprove intermittent limb compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not show that you have tried and failed four weeks of conservative therapy, specifically the use of compression stockings was not documented.
The Plan follows Medicare rules. The rules state that a PCD coded as E0650 or E0651 is covered for the treatment of lymphedema after a four-week trial of conservative therapy demonstrating failed response to compression garments, elevation, and exercise. There does not appear to be documentation of compression garments worn by member that provide adequate graduated compression starting with a minimum of 30 mmHg. There was no documentation of measurements to prove that the compression stockings were not working. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of conservative therapy. Therefore, we decided that the Plan does not have to preapprove intermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on June 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you were not aware prior authorization was needed and the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on June 10, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you had from May 22, 2021, to May 25, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that your bill incorrectly says that you had a whole body scan. You said that you had a head scan and an x-ray, but not a full body scan. You stated that because this was billed incorrectly, it is causing you to owe more. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment per day, for days 1-6 for inpatient hospital care. 
Records show that you were in the hospital for two days. You have been asked to pay a $225 copayment per day for the inpatient hospital services. This copayment applies regardless of the different services you receive while you are an inpatient. In other words, if the provider billed a whole body scan, it does not affect your copayment at all- only the days you are inpatient affect your cost sharing. 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 inpatient hospital services you had from May 22, 2021, to May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on June 23, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says 1 complete series x-ray is covered every 5 years. The Plan also says that the frequency limits have been exceeded.
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 the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on January 15, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary for your pain. The Plan denied your request. The Plan says Zilretta is only allowed once a lifetime.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Food and Drug Administration approved labeling limits this medication to a once in a life-time injection. You have previously received this drug. Therefore, the request is considered 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve the wig. You say that your medical condition is telogen effluvium. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
May 14, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you have an ambulance membership so you shouldn't have to pay this. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for the ambulance services. 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 ambulance services you received on May 14, 2021.
Your complaint about your ambulance membership is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan or the ambulance company directly. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care provided on June 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the initial observation care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the initial observation care provided on June 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom upper arm prosthesis and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current literature shows that this device does not have proven benefit. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a 
malformed body member. 
 
 The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom upper arm prosthesis and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyPro 2 Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment 
of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy 
such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement 
therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not 
reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of 
a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase  participation in 
bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyPro 2 Motion G orthotic device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction (D7140) and deep sedation/general anesthesia (D9222 and D9223) provided on April 26, 2021.
You asked the Plan to pay for the simple extraction and deep sedation/general anesthesia. The Plan denied your request. The Plan says you do not have additional preventive and comprehensive coverage through the Plan's preferred dental option.
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 simple extraction (D7140) and deep sedation/general anesthesia (D9222 and D9223) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluations, prophylaxis, bitewing x-rays, resin-based composites, first intraoral periapical x-ray, additional intraoral periapical x-ray, core buildups, including any pins when required, and crowns provided from October 8, 2020, to February 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, resin-based composites, first intraoral periapical x-ray, additional intraoral periapical x-ray, core buildups, and crowns. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that services need to be provided in-network to be eligible for payment.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluations, prophylaxis, bitewing x-rays, resin-based composites, first intraoral periapical x-ray, additional intraoral periapical x-ray, core buildups, including any pins when required, and crowns provided from October 8, 2020, to February 23, 2021 by an out-of-network (OON) provider.