Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sleep consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the sleep consultation. You say that there is no in-network provider who is 
familiar with this unique mouth equipment. You say the provider has been treating your obstructive sleep apnea 
for years. 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 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 sleep consultation 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 waive the copayment for inpatient hospital services provided from 
January 28, 2021, to February 20, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that a physician error 
occurred during an outpatient endoscopy procedure on January 28, 2021, causing a perforation in the enrollee's 
stomach lining. You stated that when she was initially discharged, you were provided with incorrect instruction 
to care for her G-tube, resulting in her needing to return to the hospital. You stated that had the doctor not 
perforated her stomach, none of this would have been necessary. You stated that you do not think you should 
have to pay for this inpatient hospital stay as a result. The Plan denied your request. The Plan says the enrollee 
was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $325 copayment per day for days 1-5, and a $0 copayment per day for days 6 to 90 for inpatient 
hospital care.  
 
The enrollee has been asked to pay a $325 copayment per day for days 1-5, and a $0 copayment per day for 
days 6 to 90 for the inpatient hospital services. This copayment applies regardless of your satisfaction with the 
care received. This means that the enrollee has been asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services 
provided from January 28, 2021, to February 20, 2021.  
 
Please note that this decision only pertains to the hospitalization from January 28, 2021, to February 20, 2021.  
In your appeal letter, you also appear to be disputing dates of service February 13, 2021, to February 19, 2021. 
The Plan has not sent us an appeal case file for those dates of service. If you wish to appeal those dates of 
service, please contact the Plan directly. 
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
You asked the Plan to pre-approve the sleeve. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that a mastectomy sleeve (L8010) is denied as non-covered. As the requested sleeve is not considered to be a prosthesis, it is not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve transcatheter placement of intravascular stent(s), cervical carotid 
artery, percutaneous (CPT code 37215), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs this procedure as their severely 
tight stenosis of the left carotid artery puts the enrollee at a risk for a stroke in the future. The Plan denied your 
request. The Plan says that this procedure is not approvable by the enrollee's Plan because research must show 
that this is as good as or better than other treatments or procedures to treat the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has been deemed high cardiac risk for carotid surgery and in addition anatomical 
factors that make a surgical approach difficult if not impossible per the recent vascular surgery evaluation. The 
enrollee has an appropriate clinical indication for carotid surgery (asymptomatic but greater than 80% stenosis) 
and open surgical repair is high risk for both medical and surgical reasons. This enrollee meets all appropriate 
published criteria for carotid stenting, and it would therefore be considered both reasonable and medically 
necessary in accordance with the applicable Centers for Medicare & Medicaid Services (CMS) rule Section 
1862 (a)1(A) and the 42 CFR Section 411.15(k). 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous (CPT code 
37215), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7240, D9222, D9223).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 dental services (D7240, D9222, D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 27, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like this claim to be reconsidered because you were unaware that you had dental coverage. The Plan denied your request. The Plan says this claim was received on May 19, 2021, which is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the periodic oral evaluation, bitewing x-rays, and prophylaxis was not filed until May 19, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and implant 
supported crown (D6066) provided on June 22, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and implant supported crown. You say that you 
would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says these 
services are not covered. The Plan also says that you did contact the Plan prior to the date of service to verify 
benefits and provider eligibility and the representative told you that these services were 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 custom fabricated abutment (D6057) and 
implant supported crown (D6066) provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus palatinus (D7472). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is the only way you will ever 
have dentures. The Plan denied your request. The Plan says this 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 
removal of torus palatinus (D7472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you desperately need this 
device because your feet and legs are extremely swollen and compression socks are not effective anymore. You 
say the in-network providers does not have appointments until January 2022. 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 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 pneumatic compression device 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 maxillary partial denture (D5211) and three surgical extractions (D7210 x3) provided on May 13, 2021, and June 11, 2021.
You asked the Plan to pay for the maxillary partial denture and surgical extractions. You say that these services were approved on March 31, 2021, and most of the procedures were done before they were denied on June 16, 2021. The Plan denied your request. The Plan says these services are not covered benefits under your 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 pay for the maxillary partial denture (D5211) and three surgical extractions (D7210 x3) provided on May 13, 2021, and June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% drops, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed artificial tears and Restasis. You state tears are not effective and Restasis is not effective. You state only Xiidra works. The Plan denied your request. The Plan says Xiidra is a self-administered drug and based on this information, the medication does not fall under Part B coverage. The Plan states the enrollee does not have pharmacy (drug) benefits administered through this health plan but does have other pharmacy benefits from a different health plan.
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 Xiidra 5% drops, for the enrollee.
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker.
You asked the Plan to pre-approve the requested walker. You say that you cannot properly stand without this walker. The Plan denied your request. The Plan says the device is 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 the requested walker. Our physician reviewer found that you have diagnoses including Parkinson's disease, chronic back pain, and osteoarthritis. You use a walker for ambulation. The requested walker is for help with posture. The request for an upright elbow walker with seat is not reasonable and necessary for the diagnosis or treatment of an illness or injury. There is no evidence that this walker will be effective and safe of your function or medical condition.
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 requested walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology, selective cellular enhancement technique with interpretation (88112) provided on December 31, 2020.
You asked the Plan to pay for the cytopathology procedure. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the cytopathology, selective cellular enhancement technique with interpretation (88112) provided on December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the present setting where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution injection.
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions. You say that the enrollee had the same procedure 2 years ago with great results. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/investigational.
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 percutaneous lysis of epidural adhesions. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous lysis of epidural adhesions have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the eye exam, refraction and eyeglasses provided on May 11, 2021.
You asked the Plan to pay more toward the eye exam, refraction and eyeglasses. You say that it is your understanding that one routine eye exam is allowed per year. You say that since this was your only routine eye exam of the year it should be covered. The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a routine eye exam and refraction from a network provider. The Plan also has a $100 benefit allowance (combined in and out-of-network) per year for eyewear. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam, refraction and eyeglasses have not been met. Specifically, the eye exam and refraction were received out-of-network and the Plan paid the maximum benefit allowance of $100 for the eyeglasses. Therefore, we decided that the Plan does not have to pay more toward the eye exam, refraction and eyeglasses provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network neurology services. You say that you would like 
reconsideration because you have been seeing this provider for 10 plus years and this provider monitors your 
neuropace. You also say that this is the only provider that does this and it will not be healthy or beneficial to 
change providers. The Plan denied your request. The Plan says you can receive the necessary care in-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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network neurology services. Our reviewer says that the requested 
out-of-network services are not medically reasonable and necessary. Our physician reviewer found the Health 
Plan has demonstrated that they have network sufficiency including the availability of providers at tertiary medical centers to manage your condition/needs and device.  Continued care with an out of network provider 
could otherwise be seen as being for your convenience. Nor can it be determined to be a service that is 
provided in a setting appropriate to the patient's medical needs and condition (versus an in network provider). 
 
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 out-of-network neurology services have not been met.  
 
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 the out-of-network neurology services. Therefore, we 
decided that the Plan does not have to pre-approve the neurology services to be provided by an out-of-network 
(OON) provider.