Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness (E2313) and electronic connection (E2311) for a power wheelchair.
You asked the Plan to pre-approve an expandable controller upgrade, harness, and electronic connection for a power wheelchair. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an expandable controller upgrade, harness, and electronic connection for a power wheelchair. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case.
Our physician reviewer found there is no documentation that it is medically necessary to control the wheelchair's power options through the joystick such that the requested controller, harness and electronic connection meet Medicare criteria for coverage. Provided records document that the enrollee has 3+/5 right upper extremity strength and is independent with all activities of daily living except bathing thus indicating he has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller upgrade, harness, and electronic connection for a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller upgrade (E2377), harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that a review of the literature indicates that PBRT is not the standard of care for prostate cancer and Proton Beam therapy for treatment of prostate cancer should only be performed within the context of a prospective clinical trial.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adding a tooth to an existing partial denture (D5650) and adding a clasp to existing partial denture (D5660).

You asked the Plan to pre-approve the tooth and clasp additions to existing partial denture. You say that you would like more money to be paid toward these services because after paying your existing bills you are low on money. The Plan denied your request. The Plan says these procedures are not covered benefits under the dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve adding a tooth to an existing partial denture (D5650) and adding a clasp to existing partial denture (D5660).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the second opinion new patient visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the second opinion new patient visit. You say that the Plan does not have the type of oncologist for your type of cancer. The Plan denied your request. The Plan says the provider is out-of-network

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the second opinion new patient visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for recurrent fevers, urinary tract infection, and splenic infarcts. Your medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for strapping provided from July 6, 2021, to August 3, 2021.
You asked the Plan to waive the copayment for strapping. You say that you required the wound care due to cancer surgery. You state that you thought that you would only owe a $20 copayment and were not aware you would owe such a high copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received strapping from an outpatient hospital facility from July 6, 2021, to August 3, 2021, for a total of 4 visits. Therefore, you are responsible to pay the allowed amount of $138.47, per each date of service. The total amount you owe is: $553.88, which is less than the total copayment amount.
You have been asked to pay the total amount of $553.88 for strapping. Strapping falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 strapping provided from July 6, 2021, to August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service July 14, 2021.
You asked the Plan to pay for procedure code 71045-26. You say that this procedure was performed and it was not a duplicate. The Plan denied your request. The Plan says payment for this code is bundled into payment for 71046 billed on the same date of service by another radiologist in the same billing group.
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, we have confirmed that code procedure code 71045-26 is a column II code to column I code 71046.
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral surgery (D7485 and D7972), anesthesia (D9222 and D9223) and a gingivectomy (D4210) provided by a participating provider.

You asked the Plan to pay for oral surgery, anesthesia, and a gingivectomy. You say that no other dentist will provide these services. The Plan denied your request. The Plan says the services being requested are not covered dental services.

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 oral surgery (D7485 and D7972), anesthesia (D9222 and D9223) and a gingivectomy (D4210) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an OON provider.
You asked the Plan to pre-approve the consultation. You say that you have knee pain, and you are requesting to
be seen by the out-of-pocket physician. The Plan denied your request. The Plan says the provider is out-ofnetwork
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 records provided for review do not show that the service at
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the consultation
to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no acute symptoms that require 24-hour inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a
review of the records provided, it is not expected that you would improve in a reasonable period of time for the dates in question, as you do not have suicidal or homicidal ideation noted. There are no auditory or visual hallucinations. You did not show any abnormal behaviors, or any symptoms that would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you do not have dangerousness to self or others, and you are compliant with treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.
You asked the Plan to pre-approve Ensure. You say that you need this drink because you are active. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, related supplies and equipment will be denied non-covered, no benefit. We looked at the file and Medicare rules. The nutrition supplement at issue is taken by mouth. Based on this information, we decided that Medicare rules for coverage of Ensure have not been met. Therefore, we decided that the Plan does not have to pre-approve Ensure
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a simple extraction (D7140).
You asked the Plan to pre-approve the extraction. You say that you would like more money to be paid toward this service because after paying your existing bills you are low on money. The Plan denied your request. The Plan says this service 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 a simple extraction (D7140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6740), a pontic-porecelain fusion (D6240), and a crown (D2740) provided by a participating provider.
You asked the Plan to pre-approve a retainer crown, a pontic-porecelain fusion, and a crown. You say that these dental services are medically necessary. The Plan denied your request. The Plan says the requested dental services are not covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6740), a pontic-porecelain fusion (D6240), and a crown (D2740) provided by a participating provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are 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. The Plan states that the MRI is not medically necessary; however, no medical records were provided for review. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lumbar MRI scan (72148) provided on April 19, 2021.
You asked the Plan to waive the copayment for the lumbar MRI scan. You say that you are being billed a copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $195 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $133.05 copayment for the lumbar MRI scan, which is less than the $195 stated in the Plan's contract. Lumbar MRI scans 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 a lumbar MRI scan (72148) provided on April 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that the physician told you that he is with the Plan and agreed to do your surgery. The Plan denied your request. The Plan says the provider is out-of-network
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 record shows the physician is out-of-network. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 2), and pontic (D6240).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the retainer crowns and pontic are not listed as covered services. The Plan also says that dental services not listed 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 retainer crowns and pontic are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750 x 2), and pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unspecified fixed prosthodontic procedures (D6999).
You asked the Plan to pre-approve unspecified prosthodontic procedures. You say that you need dental implants for your mental, emotional, and physical health. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve unspecified fixed prosthodontic procedures (D6999).