Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says previous lumbar fusion is a contraindication to the insertion of this device.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. High failure rates have been reported with similar devices. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for maintenance of non-insulin drug infusion catheter provided from January 8, 2021, through January 12, 2021.

You asked the Plan to pay for supplies for maintenance of non-insulin drug infusion catheter. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 supplies for maintenance of non-insulin drug infusion catheter provided from January 8, 2021, through January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the dental item. You say that you need an upper denture. The Plan denied your request. The Plan says complete upper denture is not listed as a covered dental item.

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 complete upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on August 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on August 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes (A5500).

You asked the Plan to pre-approve the shoes. You say that the shoes are medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support this request.

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. No medical records were provided to support the diagnosis of diabetes. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes (A5500).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller with harness, and electronic connection.

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. Medicare rules say that a power seat elevation system is non-covered. The rules say that an expandable controller with harness is used to operate multiple power features. 

We looked at the file and Medicare rules. The requested power seat elevation system is non-covered. The expandable controller with harness and electronic connection is not needed to control the approved power options. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller with harness, and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on May 26, 2021, from an out-of-network provider.
You asked the Plan to pay for hearing aids. You say that you went to the provider you purchased your hearing aids from several years ago and were assured by the out-of-network provider that you could get reimbursement if you purchased the hearing aids from them. You also say you could not get an in-network appointment for two weeks and this cost is a financial hardship for you. The Plan denied your request. The Plan says all non-Medicare covered hearing aid services must be provided by the Plan's specified hearing aid provider. The Plan also states that there were multiple providers available in-network and a sooner appointment should have been available had you contacted them about the waiting time. In addition, out-of-network providers are not agents of the Plan, but if there is evidence that a Plan representative (either from the medical plan or the hearing network) provided this information, this matter may be investigated.
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 received from a provider in the specified hearing network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met.
Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on May 26, 2021, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical consult (99205) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network surgical consult. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers that can provide the services at issue
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a surgical consult (99205) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation device (E0483).

You asked the Plan to pre-approve high frequency chest wall oscillation device. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee has a diagnosis of chronic obstructive pulmonary disease but does not have any of the listed qualifying diagnoses.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve high frequency chest wall oscillation device (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmologist visit provided on June 18, 2021.
You asked the Plan to waive the copayment for the ophthalmologist visit. You say that there should not be a charge since the appointment was made to correct an error. The Plan denied your request. The Plan says you have been charged 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 $45 copayment for each visit to diagnose or treat a disease or condition of the eye. The record shows the visit was to adjust the fitting of your glasses, which were prescribed to correct vision due to astigmatism and presbyopia. Therefore, you have been asked to pay a $45 copayment for the
ophthalmologist visit. Ophthalmologist visits fall within the Vision Care 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 an ophthalmologist visit provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) for teeth # 19 and 21, abutment supported retainer crowns (D6069) for teeth # 19 and 21, and a pontic (D6240) for tooth # 20.

You asked the Plan to pre-approve the dental services. You say that you have implants. You say that you feel it is important you get a bridge put in to help you chew. You say that you feel these services should be covered. You also say that you have to eat very soft food. The Plan denied your request. The Plan says custom fabricated abutments are not listed as covered services. The Plan says that abutment supported crowns are not listed as covered services. The Plan also says that a pontic is not covered as part of an implant supported bridge.

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 custom fabricated abutments (D6057) for teeth # 19 and 21, abutment supported retainer crowns (D6069) for teeth # 19 and 21, and a pontic (D6240) for tooth # 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on
June 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you got no notification
that this treating provider was no longer in-network. The Plan denied your request. The Plan says services
performed by an OON provider are not covered because your healthcare plan does not have OON 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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the periodic oral evaluation and prophylaxis provided on June 28, 2021 by an out-of-network (OON)
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoe inserts.

You asked the Plan to pre-approve foot orthotics. You say that this is medically 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 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 custom shoe inserts.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), an intraoral periapical first radiographic image (D0220) and seven (7) intraoral periapical additional radiographic images (D0230) provided on July 19, 2021.

You asked the Plan to pay for dental services. You say that the Plan referred you to this provider to get your teeth cleaned but when you arrived, the provider told you they had to do some x-rays. You also say you are disputing these charges as you were not aware of the five extra x-rays of your teeth. The Plan denied your request. The Plan says the requested services are not listed as covered benefits with your 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 a panoramic radiographic image (D0330), an intraoral periapical first radiographic image (D0220) and seven (7) intraoral periapical additional radiographic images (D0230) provided on July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (93609) provided on April 12, 2021.
You asked the Plan to pay for code 93609. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93609 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (93609) provided on April 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide (HHA) or certified nurse assistant (CNA) services provided from July 20, 2021, to August 5, 2021.
You asked the Plan to pay for the HHA or CNA services. The Plan denied your request. The Plan says the enrollee received these services from a provider who is not under contract with the health plan and is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA or CNA services have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home health aide (HHA) or certified nurse assistant (CNA) services provided from July 20, 2021, to August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fixed bridge.

You asked the Plan to pre-approve the fixed bridge. You say that your dentist suggested that a bridge would be the best outcome for your specific dental issue. You say that her assessment is the best course of action and the services should be approved. 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, fixed dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the fixed bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial denture (D5820).

You asked the Plan to pre-approve an interim partial denture. You say that you are requesting an appeal of the denial for a partial denture. The Plan denied your request. The Plan says any services not listed are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim partial denture (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair side guards (K0108).

You asked the Plan to pre-approve the wheelchair side guards. You say that the wheelchair side guards are medically necessary. The Plan denied your request. The Plan says this accessory is not primarily medical in nature and is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 wheelchair side guards (K0108).
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 December 28, 2020.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you have been going to this provider for at least 10 years and have had coverage with your insurance plan. The Plan denied your request. The Plan says your benefit package did not include dental coverage at the time of these services.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. 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 December 28, 2020.

Your complaint about potentially having dental coverage with the Plan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 2, 2021.

You asked the Plan to pay for the comprehensive oral exam. You say that you were told you needed unnecessary services and would like to be covered for the second opinion. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers comprehensive oral exams once every three years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on April 21, 2021. Based on this information we determined that the Plan's frequency limit for comprehensive oral exams has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 2, 2021.