Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the service is not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the fixed bridge when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the fixed bridge. Our reviewer says that the requested fixed bridge does not meet the criteria for coverage because posterior fixed bridges are not a covered expense with the Plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve the fixed bridge.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve femtosecond laser surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit and is excluded from coverage.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve femtosecond laser surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 21.

You asked the Plan to pre-approve the dental service. You say that the services should be covered. The Plan denied your request. The Plan says core build up 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 requested core build up for tooth # 21 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve further continuous positive airway pressure (CPAP) rental.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there must be a re-evaluation by the treating practitioner showing that symptoms have improved.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the compliance rate for greater than four hours of usage per night was less than 70% during the period of June through August. No in-person clinical re-evaluation has been performed. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve further continuous positive airway pressure (CPAP) rental.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable seat lift (E2300) and a Q-logic expandable joystick (K0108).

You asked the Plan to pre-approve the services. You say that the wheelchair company sent in all the paperwork needed for the appeal. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Additionally, the expandable joystick is covered in the base code of the wheelchair, and cannot be requested separately. Therefore, we decided that the Plan does not have to pre-approve an adjustable seat lift (E2300) and a Q-logic expandable joystick (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7140) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental service. You say that you need this tooth to be extracted. You say that it is beyond the expertise of any general dentist. You also say that it must be extracted by an oral surgeon. The Plan denied your request. The Plan says dental services to be provided by an oral surgeon are not covered. The Plan also says services must be performed by a participating general dentist.
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 extraction by an oral surgeon is not among those covered under this benefit. The Evidence of Coverage clearly states that services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7140) to be provided by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve genetic testing to be rendered by the out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Foot Up elastic orthosis.
You asked the Plan to pre-approve a Foot Up elastic orthosis. You say that you need this because your foot is weak and deformed. 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 a Foot Up elastic orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a wheelchair for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is a network lock-in, and 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 an out-of-network referral for a wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0480) provided on August 19, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent and there were 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 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 services at issue in this appeal.

The Plan did not pre-approve the service 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 lab services (G0480) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network cardiology services for the enrollee.

You asked the Plan to pre-approve an out of network provider. You say that the enrollee prefers to see the requested provider and you believe it's important for the enrollee to see the requested provider. The Plan denied your request. The Plan says there are provides in network who can treat the enrollee.

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 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 out of network cardiology services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531 and A6532.

You asked the Plan to pre-approve the compression stockings. You say that the items are medically necessary. The Plan denied your request. The Plan says the member does not have open venous stasis ulcers.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 and A6532 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531 and A6532.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
You asked the Plan to pre-approve the dentures. You say that the provider's office made the set of dentures and is not requiring you to pay for them. You also say that you do not have any means to pay for these dentures but need them in order to be able to eat. The Plan denied your request. The Plan says these services are not covered under your benefit 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 pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided June 29, 2021.

You asked the Plan to pay for the ambulance response with no transport. You say that the high cost of the limited services provided is unnecessary. The Plan denied your request. The Plan says the ambulance services with no transport is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 29, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The documentation in this case shows that you refused transport to the hospital because you said it was not necessary and thus the wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided June 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair accessories provided on February 23, 2021.
You asked the Plan to pay for the wheelchair accessories. You say that the patient was discharged from hospice on February 22, 2021. You say that the services were after the discharge date and the claim should be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 22, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the wheelchair accessories provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), cleaning (D1110), bitewing x-rays (D0274), panoramic x-ray (D0330), and adjunctive pre-diagnostic procedure (D0431) provided on July 7, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you followed protocol and went to an out-of-network provider and were expecting reimbursement for this claim. The Plan denied your request. The Plan says out-of-network dental care is 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. Preventative and comprehensive dental services are only covered when received by a provider who participates in the Plan's dental network.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), cleaning (D1110), bitewing x-rays (D0274), panoramic x-ray (D0330), and adjunctive pre-diagnostic procedure (D0431) provided on July 7, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies you received on August 26, 2021.
You asked the Plan to waive the coinsurance for the medical supplies. You say that you could have bought these supplies over the counter for much less. You said that you thought you had zero copays or deductibles. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment and supplies. You have been asked to pay 20% coinsurance for the medical supplies. The medical supplies fall within the durable medical equipment and 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 medical supplies you received on August 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 14, 2021.
You asked the Plan to pay for the limited oral exam. You say that you should not be responsible for the cost of the service. 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 the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on June 23, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services (97530) provided on May 31, 2021.
You asked the Plan to pay for the therapy services. 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 therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements. We find that CPT code 97530 is not supported in the record. Specifically, the record shows that this claim was billed by a nurse practitioner and the services were rendered by an Occupational Therapist. A nurse practitioner cannot bill for the services of an Occupational Therapist. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on July 27, 2021.
You asked the Plan to waive the copayment for hearing services. You say that you feel that the services were part of protocol and unnecessary because you did not request a hearing tests. 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 $35 copayment for routine hearing services provided by a specialist. The medical records show that you received hearing services on July 27, 2021. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for hearing services. Hearing services fall within the hearing 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 hearing services provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 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 physician services provided to the enrollee on May 25, 2021.