Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a radiographic implant index (D6190) and a collection of blood concentrate (D7921) to be provided by a participating provider.  You asked the Plan to pre-approve a radiographic implant index and a collection of blood concentrate. You say that you would like these services to be approved. The Plan denied your request. The Plan says the dental services requested are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a radiographic implant index (D6190) and a collection of blood concentrate (D7921) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 6, 8, and 9, and pontics (D6241) for teeth # 7 and 10.
You asked the Plan to pre-approve a fixed bridge. You say that you need a bridge because your smile and features of your face have changed. You say that it has impacted your eating and give you a cramp in your mouth. You also say that you need a bridge to build more confidence for yourself and get your smile back. The Plan denied your request. The Plan says the dental bridge is not medically necessary.
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. The Plan covers a fixed bridge when the services are medically necessary and reasonable.
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 fixed bridge. Our reviewer says that a fixed bridge is not medically necessary. Our physician reviewer found the provided documentation indicates that the radiographs provided do not coincide with the treatment proposed. The reviewer found that the radiographs provided indicate that the teeth # 6, 8, 9 and 10 to be used as abutment retainers are not present. Therefore, the reviewer found that the requested bridge 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 the Plan's rules for coverage of a fixed bridge have not been met. Specifically, the file shows that the teeth # 6, 8, 9 and 10 to be used as abutment retainers are not present. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 6, 8, and 9, and pontics (D6241) for teeth # 7 and 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device and appliance to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a pneumatic compression device and appliance to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network suppliers accessible to you that can provide the items you are requesting.  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 a pneumatic compression device and appliance to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental. More research is needed to show safety and efficacy. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator (L8679).
You asked the Plan to pre-approve an auricular stimulator. You say that the requested item/service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item/service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture is considered a non-covered service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have not been met. Specifically, the request is for an electro-acupuncture device which is a non-covered service. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator (L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).  You asked the Plan to pre-approve the system. 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 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 a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for surgical dressing kits.  You asked the Plan to waive the coinsurance for surgical dressing kits. You say that this equipment is lift sustaining and it can cost almost $5000 a year out-of-pocket.  You stated that the enrollee's previous insurer covered this at 100% and you don't understand with the Plan isn't doing the same. The Plan denied your request. The Plan says this coinsurance will be applied appropriately each time these items are purchased.  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 20% coinsurance for durable medical equipment and supplies.   The enrollee has been asked to pay 20% coinsurance for surgical dressing kits. Surgical dressing kits fall within the durable medical equipment and supplies benefit category. 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 coinsurance for surgical dressing kits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gel arm pads for a power wheelchair.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 gel arm pads for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower or bath chair.  You asked the Plan to pre-approve a shower or bath chair. You say that you were told this would be approved. The Plan denied your request. The Plan says shower or bath chairs and equipment are not covered by Medicare.  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 or bath chair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ilumya (J3245).  You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.  The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Ilumya. Our reviewer says that this drug is not medically reasonable and necessary. Our physician reviewer found in this case, the Plan requires a trial of Remicade, Inflectra, or infliximab, and Stelara before they will approve the requested drug the case file does not contain documentation of trial and failure of these drugs. In addition, there is no evidence that these drugs would likely be less effective than the requested drug, and/or would likely have adverse effects 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided July 13, 2021.  You asked the Plan to pay for the hearing aids. You say that you would like to be reimbursed for the hearing aids which were provided by a reputable provider. The Plan denied your request. The Plan says only the Plan's specified brand of hearing aids are covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are from the Plan's specified hearing aid providers and brand as described in the Plan's Evidence of Coverage.   We looked at the file, and the Plan's rules. In this case you purchased hearing aids that are not covered under your benefits. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided July 13, 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 would like an IRF admission covered. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of an IRF admission does not meet the requirements for approval.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services rendered on April 27, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted claims for procedure codes 98943 (extraspinal manipulation), 97110 (therapeutic exercises), 99203 (office visit), and 72100 (lumbosacral spine x-ray). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal x-ray rendered on August 2, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the abdominal x-ray rendered on August 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the hearing aid, digital, binaural, behind the ears (bte) (V5261) provided August 6, 2021.  You asked the Plan to provide additional payment for the hearing aids. You say that you have been given inconsistent information about your hearing benefit and would like your claim reviewed. The Plan denied your request. The Plan says the $1,000 hearing allowance has been applied to your claim and a check was sent to you on September 14, 2021. You are responsible for the remaining cost.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to a $1,000 annual allowance.   We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that the full $1,000 hearing aid allowance has been applied to the hearing aids. Therefore, we decided that the Plan does not have to provide additional payment for the hearing aid, digital, binaural, behind the ears (bte) (V5261) provided August 6, 2021.   Your complaint about being provided inconsistent information about coverage from plan representatives is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for cardiology surgical services provided on April 30, 2021.  You asked the Plan to waive the copayment for the cardiology surgical services. You say that the services should be covered in full. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.      You have been asked to pay a 20% coinsurance for cardiology surgical services (allowed amount is $3,343.44 x 20% = $668.69). Cardiology surgical services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for cardiology surgical services provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a dental exam, nerve treatment, and an x-ray provided by an out-of-network provider on July 28, 2021, to August 5, 2021.  You asked the Plan to pay for a dental exam, nerve treatment, and an x-ray. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says these services were provided by an out-of-network provider.  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 a dental exam, nerve treatment, and an x-ray provided by an out-of-network provider on July 28, 2021, to August 5, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the tendon sheath injection provided on February 10, 2021.  You asked the Plan to pay for the tendon sheathe injection. You say that this was a medically necessary treatment. The Plan denied your request. The Plan says that there is no documentation to support the medical need of this treatment.  The Plan follows Medicare rules. Medicare rules say that injections into tendon sheathes may be indicated for pain relief resulting from inflammation or other pathological changes.  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 pay for the tendon sheathe injection. Our reviewer says that the rendered procedure is shown to be medically necessary. Our physician reviewer found the medical records show a note documenting that the elderly patient has a trigger finger with locking and pain,. An injection of the tendon sheath is an appropriate first line of treatment for this 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 tendon sheathe injection have been met. Therefore, we decided that the Plan has to pay for the tendon sheath injection provided on February 10, 2021.   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 Boost nutritional supplements.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Boost nutritional supplements.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 2, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the medical records show this imagine was part of a pre-operative examination and/or outpatient procedure or surgery, are not separately covered apart from the Medicare prospective (PPS) payment.
These services were included in the facility payment for the procedure. Testing and services, part of a pre-operative examination and/or outpatient procedure or surgery, are not separately covered apart from the Medicare prospective (PPS) payment and are included in the facility prospective payment (PPS). The Plan says that Medicare Benefit Policy Manual Ch 15 for Covered Medical and Other Health Services gives direction on billing this service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, apart from the few tests listed in the Medicare rules section, are not covered. Imaging in preparation of a facility services is not separately billable. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on June 2, 2021.