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

We decided that the Plan does not have to pay for eye refractions (92015) provided August 27, 2021.

You asked the Plan to pay for the refractions. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says refractions are not covered when provided out-of-network.

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 these services when performed as part of a routine vision screening, and only when performed by a contract provider. 

We looked at the file and the Plan's rules. The refractions were not performed by a contract provider. Based on this information, we decided that the Plan's rules for coverage of the refractions have not been met. Therefore, we decided that the Plan does not have to pay for eye refractions (92015) provided August 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Partial removal of collar bone at shoulder using an endoscope (29824), Shaving of shoulder bone using an endoscope (29826), and Repair of shoulder rotator cuff using an endoscope (29827).
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 surgery is not medically necessary per Medicare rules as it is not consistent with the standard of care and exceeds the care necessary to meet your needs.
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. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. You were noted to have undergone a cortisone injection on September 9, 2021; however, there is no documentation of any physical therapy having been tried and failed.
Published, large-scale, long-term peer-reviewed literature does not support surgery without trial and failure of recent, reasonable and comprehensive conservative care measures. Our physician reviewer found that your 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 the Partial removal of collar bone at shoulder using an endoscope (29824), Shaving of shoulder bone using an endoscope (29826), and Repair of shoulder rotator cuff using an endoscope (29827).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.

You asked the Plan to pre-approve a mastectomy sleeve. You say that a mastectomy sleeve is medically necessary. The Plan denied your request. The Plan says a mastectomy sleeve is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules specifically state this item is not covered. While this item may be appropriate for your use, it is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control for a power wheelchair (E2331).
You asked the Plan to pre-approve the attendant controller. You say that the attendant controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. We looked at the file and Medicare rules. The record shows a beneficiary-operated joystick was already approved. Based on this information, we decided that Medicare rules for coverage of the attendant controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant control for a power wheelchair (E2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 19.
You asked the Plan to pre-approve the dental service. You say that you have a cracked tooth. You say that it is very painful when eating. You also say that it is affecting other aspects of your health. The Plan denied your request. The Plan says crown 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, the requested crown for tooth # 19 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve compression stockings. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture.
You asked the Plan to pre-approve the lower partial denture. You say that the dentist did the crown but never performed the partial. You say that you are depressed and want a determination as soon as possible. The Plan denied your request. The Plan says your maximum benefit has been reached.
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 complete or partial denture per arch per 60 months. The Plan paid for the lower partial denture provided on January 8, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the lower partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty to allow access for restorative procedure (D4212).

You asked the Plan to pre-approve the gingivectomy or gingivoplasty. You say that this service is necessary. The Plan denied your request. The Plan says this service is 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 a gingivectomy or gingivoplasty to allow access for restorative procedure (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950 x 3), guided tissue regeneration (D4266 x 2), second stage implant surgery (D6011 x 2), bone graft at time of implant placement (D6014 x 2), and cone beam computed tomography (CT) capture with interpretation (D0367).

You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says core build up, guided tissue regeneration, second stage implant surgery, bone graft at time of implant placement, and cone beam CT capture with interpretation are not listed as 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950 x 3), guided tissue regeneration (D4266 x 2), second stage implant surgery (D6011 x 2), bone graft at time of implant placement (D6014 x 2), and cone beam computed tomography (CT) capture with interpretation (D0367).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Venaseal procedure.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of a trial and failure of conservative therapy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has varicose veins and has had bleeding at the ankle. Ultrasound demonstrates reflux in the bilateral greater saphenous and right superficial saphenous veins. The record does not indicate that the enrollee has failed a three month trial of conservative therapy. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Venaseal procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the True Metrix blood glucose test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there are preferred products that haven't been tried.
The Plan must follow Medicare rules. Medicare rules say that blood glucose test reagent strips (A4253) are covered for beneficiaries for whom the glucose monitor is covered. The plan can limit the vendors used to receive these test strips. Despite multiple attempts, there were no records received. There is no evidence that this specific requested brand is medically necessary over the plan's preferred brands. It cannot be determined if the plan's preferred brands have been tried and failed. Based on this information, we decided that Medicare rules for coverage of the test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the True Metrix blood glucose test strips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided May 27, 2021.
You asked the Plan to pay for the psychotherapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the services is not supported without the required documentation. There is no referring physician listed on the claim
The Plan must follow Medicare rules. Medicare rules say that Provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record. There is no referring physician listed on the claim and no documentation of contact in the patient record. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided May 27, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom abutments (D6057) for teeth # 4 and 12, and implant supported crowns (D6087) for teeth # 4 and 12.
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says custom abutments are not listed as covered services. The Plan says that implant supported crowns are not listed as covered services 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, the requested custom abutments and implant supported crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom abutments (D6057) for teeth # 4 and 12, and implant supported crowns (D6087) for teeth # 4 and 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there is no reason given why the plan-preferred brand can't be used.
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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has diabetes and does not have a device that requires a particular brand of test strip. The elements of the coverage criteria are not satisfied. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2311, E2313).
You asked the Plan to pre-approve the expandable controller. You say that the controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when 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 expandable controller.
Our reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the records show that the enrollee 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 the expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, E2311, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for an office visit and duplex scans.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers within a reasonable distance.

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 for an office visit and duplex scans.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 12, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the service was incorrectly coded as outpatient surgery. The Plan denied your request. The Plan says the cost share was decreased from a $225 copayment to a $40 copayment and 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 $40 copayment for in-network physician specialist services (including surgery second opinion, telehealth, and urgently needed services).

You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontics (D6240) and retainer crowns (D6750) for a fixed bridge.
You asked the Plan to pre-approve the pontics (D6240) and retainer crowns (D6750). You say that you filed an appeal for medical coverage and still haven't heard anything. 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 pre-approve the pontics (D6240) and retainer crowns (D6750) for a fixed bridge.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral pump sets for the enrollee out of network.
You asked the Plan to pre-approve out of network providers. You say that you prefer the enrollee be allowed to use the requested provider. The Plan denied your request. The Plan says this provider is not 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 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 enteral pump sets for the enrollee out of network
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4264), three guided tissue regenerations (D4266 x3), four surgical placements of implant bodies: endosteal implants (D6010 x4), four surgical accesses to implant bodies (D6011 x4), and four bone grafts at time of implant placements (D6104 x4).
You asked the Plan to pre-approve the bone replacement graft, guided tissue regenerations, endosteal implants, surgical accesses to implant bodies, and bone grafts. You say that the reline has not improved the ability to keep your dentures from slipping. You also say that it has greatly impeded your ability to chew normally. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 bone replacement graft (D4264), three guided tissue regenerations (D4266 x3), four surgical placements of implant bodies: endosteal implants (D6010 x4), four surgical accesses to implant bodies (D6011 x4), and four bone grafts at time of implant placements (D6104 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services out of network.
You asked the Plan to pre-approve an out of network provider. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this 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 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 podiatry services out of network.