Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay for the limited oral evaluation and panoramic x-ray. We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture.   You asked the Plan to pay for the dental services. You say that this was not a regular dentist visit. You say this was a necessary procedure to check the cancer in your mouth. the services were necessary. You also say that the services should fall under your medical benefit. The Plan denied your request. The Plan says cone beam CT is not listed as a covered service. The Plan also says that this claim has been submitted to the medical claims department for review.  We decided that the Plan has to pay for the limited oral evaluation and panoramic x-ray.   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. Specifically, the file did not include documentation to support the denial of the limited oral evaluation and panoramic x-ray due to frequency limitation. Without documentation showing when the Plan paid for these services, we cannot determine if the frequency limit has been exceeded. Therefore, we decided that the Plan has to pay for the limited oral evaluation and panoramic x-ray.   We also decided that the Plan does not have to pay for the cone beam CT capture.  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 cone beam CT capture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture.  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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips.  You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.  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 50 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 trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the guided tissue regeneration and bone replacement graft provided on January 29, 2021.  You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that payment was reimbursed at a lower amount. The Plan denied your request. The Plan says the 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 pay for the guided tissue regeneration and bone replacement graft provided on January 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve thirty-six (36) visits for physical therapy (PT), speech therapy (ST) and occupational therapy (OT) each to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve PT, ST, and OT. You say that you disagree with the denial and request to appeal. The Plan denied your request. The Plan says the Plan has in-network providers who can provide 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 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. Please note, the Plan has indicated that in-network services have been approved. Please contact the Plan with questions and further information. Therefore, we decided that the Plan does not have to pre-approve thirty-six (36) visits for physical therapy (PT), speech therapy (ST) and occupational therapy (OT) each 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 pay for the panoramic x-ray (D0330) provided on August 7, 2021.  You asked the Plan to pay for the dental service. You say that that you understand that the x-ray is covered once every 36 months. You say that it seemed that this was the only option for your situation at the time. You say that you developed dry socket after an extraction. You also say that you would like help with this bill. The Plan denied your request. The Plan says full mouth x-rays are covered once every 36 months. The Plan also says that the frequency limit has 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 service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on November 12, 2019. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray provided on July 19, 2021.  You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you did not request this x-ray and were not aware you had to pay out-of-pocket. You say that you are a low-income individual and insurance should pay this bill. The Plan denied your request. The Plan says reimbursement was already issued for a comprehensive oral evaluation and panoramic x-ray.    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, you also have a maximum benefit of one comprehensive oral evaluation every three years and one panoramic x-ray every five years. The Plan paid for the comprehensive oral evaluation and panoramic x-ray provided on July 23, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray provided on July 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy provided on September 8, 2021, by an OON provider.  You asked the Plan to pay for the psychotherapy. You say that the provider group is in-network and does not require a referral. 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. Therefore, we decided that the Plan does not have to pay for the psychotherapy provided on September 8, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for physician services and Medicare Part B drugs provided on February 11, 2021.  You asked the Plan to waive the coinsurance for physician services and Medicare Part B drugs. You say that you were pre-approved to see the physician and disagree with the out-of-network charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for out-of-network physician/practitioner services, including doctor's office visits and Medicare Part B prescription drugs.   You received physician services and Medicare Part B drugs from an out-of-network provider on February 11, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $285.94 and 30% of that is $85.79.   You have been asked to pay the total coinsurance amount of $85.79 for physician services and Medicare Part B drugs. Physician services fall within the physician/practitioner services, including doctor's office visits benefit category. 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 physician services and Medicare Part B drugs provided on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.  You asked the Plan to pre-approve a Vertiflex Superion interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a Vertiflex Superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has scoliosis of 35 degrees and severe central canal stenosis at the requested level for treatment. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.   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 Vertiflex Superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Simponi Aria.  You asked the Plan to pre-approve Simponi Aria. 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 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 Simponi Aria. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Simponi Aria is medically reasonable and necessary for the enrollee. The documentation does not support that the Simponi Aria is safe and effective for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have foot and heal pain. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair glide.  You asked the Plan to pre-approve a stair glide. You say that this would be a boost to your health mentally and physically. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the items are necessary. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the wheelchair frame.  You asked the Plan to pre-approve the wheelchair frame. You say that the item should be covered. The Plan denied your request. The Plan says this item is covered under a manufacturer warranty.  The Plan must follow Medicare rules. Medicare rules say that under the circumstances specified below, payment may be made for repair, maintenance, and replacement of medically required DME, including equipment which had been in use before the user enrolled in Part B of the program. However, do not pay for repair, maintenance, or replacement of equipment in the frequent and substantial servicing or oxygen equipment payment categories. In addition, payments for repair and maintenance may not include payment for parts and labor covered under a manufacturer's or supplier's warranty.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair frame have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair frame.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you need a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the psychoanalysis services (90845) to be provided by a Licensed Mental Health Counselor Associate.
You asked the Plan to pre-approve the psychoanalysis services. You say that you understand Medicare does not accept LMHCA (licensed mental health counselor associate) but you know this is being challenged right now in congress and is likely to change. The Plan denied your request. The Plan says neither Medicare nor the plan will cover treatment by the requested provider type.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. The Health Plan contract says that you can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can find this information on page 33 of the Plan's 2021 EOC. Review of the file and Medicare records indicates that the provider at issue is a Licensed Mental Health Counselor Associate and is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve the psychoanalysis services (90845) to be provided by a Licensed Mental Health Counselor Associate.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a PILD procedure (0275T).  You asked the Plan to pre-approve a PILD procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met because the enrollee is not enrolled in an approved clinical study.  The Plan must follow Medicare rules. Medicare rules say that the PILD procedure will be covered for beneficiaries who are enrolled in an approved clinical study.   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 PILD procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the clinical documentation supports that the requested PILD procedure is medically reasonable and necessary for the enrollee in this case. The enrollee in this case would be passively enrolled in an observational study for all Medicare patients who receive the procedure at issue. As a result, the coverage criteria have been met in this case.  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 PILD procedure have been met. Therefore, we decided that the Plan has to pre-approve a PILD procedure (0275T).   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have been using orthotics for your severe foot issues for many years. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you are in pain from a bone spur, tendonitis, and plantar fascia. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a grab bar.  You asked the Plan to pre-approve a grab bar. You say that you have very bad back pain and unable to walk or take shower. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature.   While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.