Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated vehicle for the enrollee.  You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation to indicate this request.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 vehicle. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, neoplasm of lower lung, restless leg syndrome, knee pain following replacement, and lumbar degenerative disc disease. The record provided does not address the elements of the coverage criteria of the requested service. 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 vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal for a premolar tooth (D3320), and treatment of a root canal obstruction (D3331).  You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says endodontic services including root canals and treatment of root canal obstruction 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 root canal and treatment of root canal obstruction are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal for a premolar tooth (D3320), and treatment of a root canal obstruction (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the five surgical extractions (D7210 x5) and deep sedation/general anesthesia (D9222 and D9223) provided on May 26, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the surgical extractions and deep sedation/general anesthesia. You say that you were told this provider accepted your insurance. You also say that you are disabled, and this bill presents a hardship on you. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective March 28, 2014, to March 28, 2022.  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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the five surgical extractions (D7210 x5) and deep sedation/general anesthesia (D9222 and D9223) provided on May 26, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for topical application of fluoride (D1206) provided by a participating provider.  You asked the Plan to pay for topical application of fluoride. You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says D1206 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 pay for topical application of fluoride (D1206) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on June 9, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you requested to return the equipment and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 0% coinsurance for items with a total rental or purchase value of $350 or less of the Medicare allowable rate per item and 20% for items with a total rental or purchase value of $350.01 or more of the Medicare allowable rate per item for DME and related supplies.   The record shows that you received DME and related supplies on June 9, 2021. The total allowed amount is $1,502.82 and 20% of that is $300.56.   You have been asked to pay the total coinsurance amount of $300.56 for DME and related supplies. DME and related supplies fall within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the complete overdenture (D5865).  You asked the Plan to pre-approve the complete overdenture (D5865). You say that this is the only lower denture that you can wear due to bone recession. The Plan denied your request. The Plan says the service 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 the complete overdenture (D5865).
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for durable medical equipment provided on July 15, 2021.  You asked the Plan to pay for durable medical equipment. The Plan denied your request. The Plan says the fee-for-service (FFS) benefit is the time where the member revokes hospice till the start of the new month. During this time Traditional or Original Medicare is still responsible for payment of medical services both unrelated and related to the hospice diagnosis. This benefit also covers any service unrelated to the hospice diagnosis during active hospice periods prior to the Medicare Advantage plan considering the claim for payment.  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 durable medical equipment provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for initial hospital observation care services provided on  July 20, 2021.  You asked the Plan to pay for initial hospital observation care services. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for initial hospital observation care services provided on  July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on June 25, 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 enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the enrollee on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral out-of-network for custom shoe supports.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available 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 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 referral out-of-network for custom shoe supports.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on August 20, 2021.  You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says your Plan benefit does not cover out-of-network vision services.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a network optical provider.   We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on January 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on January 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) provided on September 28, 2021.  You asked the Plan to waive the copayment for specialist office visit. You say that the services should be covered as you were not made aware of the co-payment in advance. 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 $40 copayment for Physician/Practitioner services, including doctor's office visits.    You have been asked to pay a $40 copayment for specialist office visit. The record indicates that these services were rendered by a specialist. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits 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 a specialist office visit (99204) provided on September 28, 2021.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to pay for the outpatient hospital services provided from December 16, 2020, to December 17, 2020.  You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has not provided documentation to support their reasoning for the denial of payment based on Medicare rules. Therefore, we decided that the Plan has to pay for the outpatient hospital services provided from December 16, 2020, to December 17, 2020.   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 a vehicular carry box for a power mobility device.  You asked the Plan to pre-approve a vehicular carry box. You say that the requested item is a necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item does not serve a primarily medical purpose.  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 vehicular carry box for a power mobility device.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Pegfilgrastim-Cbqv.  You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says that the enrollee's cancer treatment has a low risk for fever.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 drug. Our physician reviewer found that the enrollee has metastatic non-small cell lung cancer. The requested use of Pegfilgrastim is FDA-approved for the enrollee's diagnosis. He is at risk for neutropenic fever given his age and absolute neutrophil count (ANC) of 600 with urinary tract infection. The requested use of the drug is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 the requested drug have not been met. Therefore, we decided that the Plan has to pre-approve Pegfilgrastim-Cbqv.   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: Favorable

 We decided that the Plan has to pre-approve an expandable controller (E2311, E2377, E2313).  You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not need to operate power options through a joystick.  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 an expandable controller. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found while the records show that the enrollee has 3/5 bilateral arm strength, her hand and wrist strength are reported as 1/5 to 1+/5. The records show that she has neuropathy and poor hand dexterity requiring the requested expandable controller, harness and electrical connection.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have been met. Therefore, we decided that the Plan has to pre-approve an expandable controller (E2311, E2377, E2313).   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 compression stockings identified with code A6549 for the enrollee.  You asked the Plan to pre-approve the compression stockings. You say that these compression stockings are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.  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 Eliquis.   Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85027), the intralesional injection (11900), and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on July 14, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85027), the intralesional injection (11900), and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on July 14, 2021.