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

We decided that the Plan does not have to pre-approve an additional pair of eyeglasses.
You asked the Plan to pre-approve an additional pair of eyeglasses. You say that it is necessary for a second
pair of eyeglasses to be covered for your condition. The Plan denied your request. The Plan says their benefit
only allows one pair of eyeglasses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of eyeglasses every 2 years. We looked at the file and the Plan's rules. In this case, the Plan has covered 1 pair of eyeglasses. A second will not be covered based on the terms of their routine vision benefit. Based on this information, we decided that the Plan's rules for coverage of an additional pair of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional pair of eyeglasses.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.

You asked the Plan to pre-approve a MILD procedure. You say that the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.

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 a MILD procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the MILD procedure is experimental. More research is needed to demonstrate the safety and efficacy of the procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialist visit. You say that you need to be seen by a provider to determine if you are a qualifying candidate for treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.

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 second opinion visit 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 the gradient compression wrap (CPT code A6545).

You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. According to the records, the requested compression garments are not being used to treat open venous stasis ulcers (wounds caused by poor blood-flow). Therefore, we decided that the Plan does not have to pre-approve the gradient compression wrap (CPT code A6545).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1 gm capsule.

You asked the Plan to pre-approve Vascepa. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

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 Vascepa 1 gm capsule.

Benefits for Vascepa 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to go to LTACH to assist with decannulation, trachea weaning, and intravenous (IV) antibiotics. You state the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says once the enrollee finishes their care in the hospital, they will not need daily physician visits, and not have needs for specialty nursing care. The Plan states the enrollee is recovering from an acute illness. However, they will need continued care, including skilled nursing care and skilled therapy. The Plan states the enrollee can safely receive this care in another setting, such as a skilled nursing facility (SNF).

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH.

The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that the enrollee has had success with Trulicity. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
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 Trulicity.
Benefits for Trulicity 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), three additional intraoral periapical x-rays (D0230 x3), and maxillary partial denture (D5225), and to pay more for the comprehensive oral evaluation (D0150) provided on September 30, 2021, and October 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the intraoral periapical x-rays and maxillary partial denture, or pay more for the comprehensive oral evaluation. You say that you were at the dental office when the receptionist called the Plan and was advised that you were covered 100% in-network, and 50% OON. You also say that it is unacceptable that the dental office was given misinformation, and now you are responsible for the entire balance. The Plan denied your request.
The Plan says the intraoral periapical x-rays and maxillary partial denture these services are not covered expenses under your dental plan. The Plan says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that neither you nor the provider contacted the Plan prior to these dates 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, the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and maxillary partial denture (D5225) are not among those covered under this benefit. You are responsible for a 50% coinsurance for the comprehensive oral evaluation (D0150), plus the difference between the billed amount and allowed amount because the service was received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), three additional intraoral periapical x-rays (D0230 x3), and maxillary partial denture (D5225), and to pay more for the comprehensive oral evaluation (D0150) provided on September 30, 2021, and October 5, 2021 by an out-of-network (OON) provider.
Your complaint about the receptionist being given misinformation 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 recement of crown (D2920) provided on September 28, 2021.

You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says recement of crown is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the recement of crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the recement of crown (D2920) provided on September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the pelvis.
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says there is no
documentation of what is trying to be ruled out.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 a CT scan. Our physician reviewer
found that the enrollee has right hip pain despite medications and injections. There is no specific clinical
rationale for the requested CT scan of the pelvis. The review has determined that the requested CT scan 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 a CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a computed tomography (CT) scan of the pelvis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from October 16, 2020, to October 20, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee's condition was evaluated, monitored, and treated. The Plan denied your request. The Plan says the documents did not validate the diagnosis
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with G93.41, defined as metabolic encephalopathy. 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 services provided. Our physician reviewer found that the enrollee with mild dementia was admitted to the hospital with nausea and vomiting. She was treated for pneumonia and a urinary tract infection. She was given fluids and antibiotics. Secondary diagnosis of metabolic encephalopathy was reported. The provided records described the enrollee as alert and oriented, but hard of hearing in the emergency room, and had a normal neurological examination. There was no imaging indicating encephalopathy was present. Therefore, documentation does not support metabolic encephalopathy as a secondary diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from October 16, 2020, to October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you are in unbearable pain. The Plan denied your request. The Plan says there are in-network providers available.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-network (OON) provider.
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 to prevent serious
cardiovascular events. The Plan denied your request. The Plan says the drug is not eligible for coverage under
the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (ovarian), biochemical assays of five proteins (81503) provided on September 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for oncology (ovarian), biochemical assays of five proteins. You say that considering this assay's unparalleled ability to detect ovarian malignancy, its sole source status and the role the assay has in treatment for decisions for women facing surgery, neither the beneficiary nor the ordering physician should be penalized. You also say that as such, you respectfully request that the Plan reprocesses the claim as a covered benefit. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider. The Plan also says they have 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 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 oncology (ovarian), biochemical assays of five proteins (81503) provided on September 22, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the crown (D2740) provided on October 28, 2021.
You asked the Plan to pay the full amount for the crown. You say that you do not understand how you have reached your maximum. The Plan denied your request. The Plan says there is a maximum allowance of $1,500 for covered dental services. The Plan also says that the maximum allowance has been exhausted.
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 maximum allowance has been exhausted. The record shows that the Plan paid $169 for services you received on April 2, 2021. The record shows that the Plan paid $88 for the limited oral evaluation, $35 for the periapical x-ray, and $1,208 towards the crown received on the date of service in this case. $169 + $88 + $35 + $1,208 = $1,500. Additionally, the Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay the full amount for the crown (D2740) provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says settings that could be delivered by a BiPAP device are not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our physician reviewer found that you have severe COPD, but an arterial blood gas shows a normal partial pressure of carbon dioxide. Therefore, you do not meet criteria for nocturnal respiratory support with BiPAP and does not require a home ventilator. In addition, the requested Life2000 system is not a ventilator. It is not capable of providing full ventilatory support, and is intended for use during activity, not while sleeping. There is inadequate evidence that the Life2000 is beneficial in COPD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says services are 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve dialysis services to be provided 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 telehealth visit provided on
September 14, 2021.
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you had a 6 minute
conversation and you refused the charges. 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 $40
copayment for telehealth services with your specialist provider.
You have been asked to pay a $40 copayment for the specialist telehealth visit. The specialist telehealth visit
falls 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 telehealth visit provided on September 14, 2021.