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

We decided that the Plan does not have to provide coverage for additional non-emergency, routine transportation trips.

You asked the Plan to provide coverage for additional non-emergency, routine transportation trips. The Plan
denied your request. The Plan says the evidence shows the enrollee has used seventeen (17) one-way trips of
the eighteen (18) one-way trips covered by his health Plan for the year 2021. The enrollee has one (1) one-way
trip available.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers eighteen (18) trips, one-way trip or return trip, each year.

We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers a
maximum of eighteen (18) trips each year. Therefore, we decided that the Plan does not have to provide
coverage for additional non-emergency, routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 3, 2021.  You asked the Plan to pay for the dental service. You say that your dentist has a 2-step cleaning process. You say that that this was the second step. You also say that this should be covered. The Plan denied your request. The Plan says 1 cleaning is covered per calendar year. The Plan also says that the frequency limit has been exceeded.  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.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The file shows that the Plan paid for scaling in presence of generalized moderate or severe gingival inflammation provided on June 4, 2021. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 You asked the Plan to pre-approve shoulder brace and cold pad. You say that you had surgery and need this equipment. The Plan says that the denial of authorization for these items is correct, because the requested shoulder brace is not medically necessary, and a cold pad is not covered by Medicare.  We decided that the Plan has to pre-approve shoulder brace.   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 shoulder brace and cold pad. Our reviewer says that the requested should brace is medically reasonable and necessary. Our physician reviewer found you were being treated for primary osteoarthritis of the right shoulder. You were planned to undergo a right reverse total shoulder arthroplasty. There is pain in your right shoulder. Examination reveals tenderness, weak elevation, and decreased range of motion with pain. Immobilization has been proven effective post-surgery when utilized intermittently for repair protection and pain control.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder brace have been met. Therefore, we decided that the Plan has to pre-approve shoulder brace.   We also decided that the Plan does not have to pre-approve cold pad.  The Plan follows Medicare rules. Medicare rules state that a fluid circulating cold pad with pump is not covered by Medicare and will be denied as not reasonable and necessary.   We looked at this the file and Medicare rules. The requested fluid circulating cold pad with pump is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of cold pad have not been met. Therefore, we decided that the Plan does not have to pre-approve cold pad.  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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on
February 11, 2021.
You asked the Plan to waive the copayment for vision services. The Plan denied your request. The Plan says
our records indicate that this service was follow up care for vision services.
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 Vision Care, Medicare-covered vision services.
You have been asked to pay a $40 copayment for vision services. The vision services falls within the Vision
Care, Medicare-covered vision services 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 vision services provided on February 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve a wig. You say that you are going through chemotherapy. The Plan denied your request. The Plan says the requested item is not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lower extremity you had on August 4, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you do not believe you should be charged two separate copayments for two doctors reading the same MRI The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for high tech imaging services. You have been asked to pay a $295 copayment for the MRI. We confirmed that you were not charged two
separate copayments for the MRI of the lumbar spine. The records show that on this date of service, you had
an MRI of the lumbar spine and an MRI of the lower extremity. The MRI of the lower extremity was billed by
a different provider than the MRI of the lumbar spine. These are two separate and distinct tests that each carry
their own copayment. the MRI falls within the high tech imaging services 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 the magnetic resonance imaging (MRI) of the lumbar spine you had
on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471).

You asked the Plan to pre-approve the removal of lateral exostosis. You say that this procedure is required for your dentures to fit. The Plan denied your request. The Plan says this service is 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 removal of lateral exostosis (D7471).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635, 64636).

You asked the Plan to pre-approve a radiofrequency ablation. You say that you have always had greater than 2 of the requested procedures per year and were not informed of a change. The Plan denied your request. The Plan says rules for coverage for the procedure at issue have not been met.

The Plan must follow Medicare rules. Medicare rules say that, for each covered spinal region, no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiofrequency ablation have not been met. Specifically, the medical record documents that you have already been provided two radiofrequency sessions within the last 12 months. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for OneTouch Verio testing strips.
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 eligible for a tier exception.
The Plan must follow Medicare rules. Medicare rules say that Part B services are not eligible for a Part D tier
exception.
We looked at the file and Medicare rules. The requested diabetic testing supplies are covered by Part B
Medicare and are not eligible for a Part D tier exception. 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 a tier exception for OneTouch Verio testing strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.

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. 

The file shows that a power wheelchair has been assessed as not appropriate for the enrollee and the enrollee's home provides adequate access, proper space, and flooring for using a power wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a mandibular partial denture (D5226) and a maxillary partial denture (D5225) provided by a participating provider.

You asked the Plan to pay for a mandibular partial denture and a maxillary partial denture. You say that you would like the Plan to pay for the partial dentures. The Plan denied your request. The Plan says the requested partial denture 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 a mandibular partial denture (D5226) and a maxillary partial denture (D5225) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for hearing aids provided on June 4, 2021.
You asked the Plan to pay an additional amount for the hearing aids. You say that in looking over your
out-of-pocket payments to date, this $4,150.00 is not included. You say the cost of the hearing aids should be
applied to your out-of-pocket payments. The Plan denied your request. The Plan says the total cost share
amount of $4,150.00 was applied correctly.
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.
We looked at the file and the Plan's rules. The file shows that the total cost share amount of $4,150.00 was
applied correctly. Therefore, we decided that the Plan does not have to pay an additional amount for hearing
aids provided on June 4, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound and a specialist visit provided on May 14, 2021.
You asked the Plan to waive the copayments for an ultrasound and a specialist visit. You say that you disagree with the charges because you only requested to have a callus removed and were not told you would be charged. 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 a $110 copayment for radiological diagnostic services, including ultrasounds. Your contract with the Plan also clearly says that you must pay a $35 copayment for specialist visits. You received an ultrasound on May 14, 2021. Therefore, you are responsible to pay the allowed amount of $109.80, which is less than the $110 copayment. You had a specialist visit on May 14, 2021. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $144.80. You have been asked to pay the total copayment amount of $144.80 for an ultrasound and a specialist visit. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A specialist visit falls within he physician/practitioner services, including doctor's office visits. 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 copayments for an ultrasound and a specialist visit provided on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that it is felt that the Superion procedure is a good option for this patient. The Plan denied your request. The Plan says this procedure is experimental.

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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration (FDA) stated that the Superion device is indicated for placement at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis including the planned level of implantation at L5/S1 or L4/L5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of S curvature of the thoracolumbar spine of the lumbar spine with no documentation of the Cobb angle. There is no evidence of a bone density test showing a lack of significant osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion device at L5/S1 or L4/L5 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 Medicare rules for coverage of the Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on
December 3, 2020.
You asked the Plan to waive the copayment for vision services. The Plan denied your request. The Plan says
you are responsible for $45 copay for each Medicare-covered vision service.
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 vision care, Medicare-covered vision services.
You have been asked to pay a $45 copayment for vision services. The vision services falls within the vision
care, Medicare-covered vision services 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 vision services provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain pump trial.
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your request. The Plan says there is already an implanted spinal cord stimulator.
The Plan must follow Medicare rules. Medicare rules say that the implantation of an infusion pump is contraindicated with other implanted programmable devices since crosstalk between devices may inadvertently change the prescription. The requested trial cannot be approved as you already have a spinal cord stimulator. This stimulator is a contraindication for a pain pump. Based on this information, we decided that Medicare rules for coverage of the trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a pain pump trial
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on April 21, 2021.
You asked the Plan to pay for hearing aids. You say that there was no mention of a vendor, and it was difficult
for you to contact anyone during the pandemic. The Plan denied your request. The Plan says there is no
coverage if hearing aids, or related services are received from a provider that is not part of the Plan's hearing
aid vendor's network.
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 provided by the Plan's hearing aid vendor.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's
hearing aid vendor's 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 hearing aids
provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on August 4, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the debridement services. You say that the services are medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.
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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the debridement services provided on August 4, 2021, by an out-
of-network (OON) provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 9, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 9, 2021.