Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from April 7, 2021, to April 26, 2021.

You asked the Plan to waive the copayments for the physical therapy visits. You say that you did not received services on these dates of service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $30 copayment for each in-network Medicare-covered Occupational Therapy, Physical and/or Speech and Language Therapy visits. 

You have been asked to pay a $30 copayment for each of the physical therapy visits. The physical therapy visits fall within "Outpatient rehabilitation services" benefit category. The medical record shows services were provided on the dates of service at issue.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy visits provided from April 7, 2021, to April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March
2, 2021, and March 5, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that you
would not owe anything for the treatment. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs on March 2, 2021. The total allowed amount is $2,622.18 and 20% of that
is $524.44.
You received Medicare Part B drugs on March 5, 2021. The total allowed amount is $2,622.18 and 20% of that
is $524.44.
The total amount you owe is: $1,048.88.
You have been asked to pay the total coinsurance amount of $1,0488.88 for Medicare Part B drugs. Medicare
Part B drugs fall within the Medicare Part B prescription drugs 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 for Medicare Part B drugs provided on March 2, 2021, and March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are not at a functional level to be at home and do not have the skills to get out of bed. The Plan denied your request. The Plan says the denial of authorization IRF service is correct.
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 the complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43270) to be provided at an out-of-network facility.

You asked the Plan to pre-approve an esophagogastroduodenoscopy. You say that the requested procedure is a necessity for your care. The Plan denied your request. The Plan says rules for out-of-network care have 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (43270) to be provided at an out-of-network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for wound care. You say that these services were provided in an approved skilled nursing facility. You say that this should be covered. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 wound care provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010 x 2), custom abutments (D6057 x 2), and bone grafts at the time of implant placement (D6104 x 2).

You asked the Plan to pre-approve the dental services. You say that your enrolling agent told you that dental implants would be covered at 75% in network. The Plan denied your request. The Plan says implants and related 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 implants and related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants (D6010 x 2), custom abutments (D6057 x 2), and bone grafts at the time of implant placement (D6104 x 2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Veltassa powder 8.4gm.
You asked the Plan to pre-approve the Veltassa powder. You say that the patient is chronically hyperkalemic and must continue this medication. You say that she cannot afford the cost and her life will be jeopardized due to cardiac events. The Plan denied your request. The Plan says outpatient prescription drugs are not covered under.
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 the Veltassa powder 8.4gm.
Benefits for the Veltassa powder 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (35903) provided on February 8, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the surgical payment.

The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global surgical procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery. 

We looked at the file and Medicare rules. Payment for the services in question is included in the global surgical package for the procedure (36830) provided on November 25, 2020. This procedure has a 90-day global surgery period. 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 (35903) provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the attachment hardware and side guards (K0108).
You asked the Plan to pre-approve the attachment hardware and side guards. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not primarily medical in nature.
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 the attachment hardware and side guards (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visits. You say that you have been seeing this provider for years and want to continue care with this provider. You do not want to start all over with a new doctor. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visits 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 a partial upper denture with flexible base (D5225), and a partial lower denture with flexible base (D5226).

You asked the Plan to pre-approve the dental services. You say that the partial dentures are medically necessary. The Plan denied your request. The Plan says partial dentures with flexible bases are not listed as covered 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 partial dentures with flexible bases are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225), and a partial lower denture with flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950),
three pontics (D6240 x3), and three retainer crowns (D6750 x3) provided on May 21, 2021.
You asked the Plan to pay for the core buildup, pontics, and retainer crowns. You say that you were given an
estimate of $3,675.00 for these services and were told that you would be responsible for the cost because your
insurance does not cover bridgework. You also say that it appears you and your insurance were both charged
for some of the items, and you would like to be refunded in the amount of $309.00. 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 core
buildup, including any pins when required (D2950), three pontics (D6240 x3), and three retainer crowns
(D6750 x3) provided on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion 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 the clinical evaluation for low back pain and spine fusion is lacking.
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. The enrollee has low back pain. The provided records generally are post-operative follow-ups from cervical spine surgery. There is no documentation of conservative treatment failure. 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 lumbar fusion for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585), 181 units each side, every 10 weeks.

You asked the Plan to pre-approve Botox every 10 weeks. You say that injections every 3 months helps immensly with the enrollee's vision. You say that the enrollee will need to come in every 10 weeks. The Plan denied your request. The Plan says the drug is not medically necessary.

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 Botox every 10 weeks. Our reviewer says that Botox every 10 weeks is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that supports that the Botox injections every 10 weeks are medically reasonable and necessary for the enrollee. The reviewer found that there is no documentation that supports that the Botox injections every 10 weeks are safe and effective for the enrollee. Therefore, the reviewer found that the requested frequency of every 10 weeks 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 Botox every 10 weeks have not been met. Specifically, the record does not support dosing of Botox more frequently than every 12 weeks for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585), 181 units each side, every 10 weeks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a vascular surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in the 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 an out-of-network referral to a vascular surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a basket for a power operated vehicle.

You asked the Plan to pre-approve these services. You say that your scooter needs a basket to be balanced. The Plan denied your request. The Plan says the item is not covered.

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. Therefore, we decided that the Plan does not have to pre-approve a basket for a power operated vehicle.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home skilled nursing visit for laboratory services.
You asked the Plan to pre-approve the home skilled nursing visit. You say that you do not understand why this service was denied because it is comparable to your last request. The Plan denied your request. The Plan says home health for the sole purpose of routine blood draws and urine sample collection is not a covered benefit by Medicare.
The Plan must follow Medicare rules. Medicare rules say that for coverage of intermittent home health skilled nursing care, the enrollee must need skilled nursing care that is not solely needed for venipuncture for the purposes of obtaining a blood sample. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home skilled nursing visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a home skilled nursing visit for laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the lower left and lower right quadrants, gingival irrigation (D4921) for all4 quadrants, alveoloplasty in conjunction with extractions, 1 to 3 teeth per quadrant, (D7311) for the upper right and upper left quadrants.

You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says scaling and root planing is covered once every 3 years per quadrant. The Plan says that the frequency limit has been reached. The Plan says that gingival irrigation is not listed as a covered service. The Plan also says that alveoloplasty in conjunction with extractions, 1 to 3 teeth per quadrant, is not listed as a covered service either.

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 scaling and root planing is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for scaling and root planing for the lower left and right quadrants that you received on May 18, 2021. Additionally, the requested gingival irrigation and alveoloplasty in conjunction with extractions, 1 to 3 teeth per quadrant, are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the lower left and lower right quadrants, gingival irrigation (D4921) for all4 quadrants, alveoloplasty in conjunction with extractions, 1 to 3 teeth per quadrant, (D7311) for the upper right and upper left quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower denture (D5120), and removal of extra bone in root of mouth (D7473).

You asked the Plan to pre-approve the dental services. You say that you have gone back for multiple adjustments to your dentures, but they still do not fit properly. You say that another dentist confirmed that you needed surgery and to throw out your old dentures. You also say that you need a new set of dentures. The Plan denied your request. The Plan says dentures are covered once every 60 months. The Plan says that the frequency limit has been reached. The Plan also says that removal of extra bone in roof of mouth is not listed as a covered service.

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 covered, the frequency limit has been reached. The record shows that you previously received dentures on February 13, 2020. Additionally, the requested removal of extra bone in roof of mouth is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower denture (D5120), and removal of extra bone in root of mouth (D7473).