Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the post and core in addition to crown (D2952) provided on January 12, 2021.  You asked the Plan to pay for the post and core. You say that you were told that this service was pre-approved before it was provided to you. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the post and core in addition to crown (D2952) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on July 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the nursing facilities responsibility to get authorizations for their patients. You also say that you did not know that the facility failed to get preauthorization for this patient, so you treated the patient anyway. The Plan denied your request. The Plan says this service was not authorized.  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 a domiciliary or rest home visit (99335) provided on July 23, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device (22869).  You asked the Plan to pre-approve the insertion of a Vertiflex Superion device. You say that this is medically necessary. The Plan denied your request. The Plan says this treatment is unproven.  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 insertion of a Vertiflex Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. more research is needed to show it is safe and effective.  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 insertion of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the labial veneer (resin laminate) - direct (D2960) provided July 20, 2021.  You asked the Plan to pay for the labial veneer. You say that this was a required part of a previous procedure. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the labial veneer (resin laminate) - direct (D2960) provided July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone Acetaminophen.

You asked the Plan to pre-approve the requested drug. 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 Hydrocodone Acetaminophen.

Benefits for the requested drug 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation: wheelchair van (A0130), 3 round trips per week starting January 3, 2022.  

You asked the Plan to pre-approve the transportation services. You say that you do not drive. You also say that you can die without dialysis. The Plan denied your request. The Plan says wheelchair van transportation between your home and medical appointments is not a covered benefit.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   

The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation: wheelchair van (A0130), 3 round trips per week starting January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ophthalmological services, medical examination and evaluation with initiation of diagnostic and treatment program to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve ophthalmological services, medical examination and evaluation with initiation of diagnostic and treatment program to be provided by the requested out-of-network provider. You say that this physician provides stem cell therapy. The Plan denied your request. The Plan says that the Plan does not cover out-of-network services rendered with the exceptions of the emergency care or urgently needed services that you get from an out-of-network provider. This includes worldwide coverage if covered by your Plan. If you need medical care that Medicare requires our Plan to cover and providers in our network cannot provide this care, you can get this care from an out-of-network provider. For these types of referrals, you must obtain authorization before seeking care. In this situation, we will cover these services as if you got the care from a network provider. If you do not have a prior authorization before you receive services from an out-of-network provider, you may have to pay for these services yourself. Renal dialysis services when you are temporarily outside the service area, or when prior authorized.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmological services, medical examination and evaluation with initiation of diagnostic and treatment program to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on July 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that the services should be covered as you called the doctor's office and were informed that the services would be covered. The Plan denied your request. The Plan says the services will not be covered as this office visit was rendered by an out-of-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 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 an office visit (99214) provided on July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex-C.

You asked the Plan to pre-approve Gamunex-C. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Gamunex-C is only covered for certain indications.

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 Gamunex-C. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has a diagnosis of D80.1 defined as Nonfamilial hypogammaglobulinemia. This is
not an enumerated condition in the coverage determination for which coverage is available under part B. The
elements of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the
requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gamunex-C.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acupuncture, initial 15 minutes (97813) acupuncture, each additional 15 minutes (97814) for the treatment of knee pain.  You asked the Plan to pre-approve the acupuncture services. You say that please reconsider your appeal and reinstate your acupuncture services. It was used appropriately and well, for your benefit. The Plan denied your request. The Plan says conditions other than that of chronic low back pain is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture for any other condition other than chronic low back pain is not covered. The health Plan contract says that no more than 20 acupuncture treatments may be administered annually. The Plan had previously approved 14 acupuncture treatments. 6 additional acupuncture treatments are approved and the benefit is now exhausted. Acupuncture for any  Therefore, we decided that the Plan does not have to pre-approve acupuncture, initial 15 minutes (97813) acupuncture, each additional 15 minutes (97814) for the treatment of knee pain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on September 30, 2020, and October 1, 2020.  You asked the Plan to pay for the bitewing x-rays and prophylaxis. You say that you never requested or approved the x-rays that were taken, and feel you were overcharged for them. The Plan denied your request. The Plan says you met your $200 allowance.  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 Plan offers a $200 allowance per year for preventive dental services. The record shows that you met the annual maximum benefit on September 30, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and prophylaxis (D1110) provided on September 30, 2020, and October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the preventive procedure (D1999) and complete series of intraoral x-rays (D0210) provided on July 23, 2021.  You asked the Plan to pay for the preventive procedure and complete series of intraoral x-rays. You say that you were told that the x-rays and cleaning were covered, and you were unaware of a five-year limit on the x-rays. The Plan denied your request. The Plan says unspecified preventive procedure is not a covered expense under your dental plan. The Plan also says that your benefits for the complete series of intraoral x-rays have been satisfied and the frequency limitation 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified preventive procedure (D1999) is not among those covered under this benefit. The Plan contract says that full mouth or panoramic x-rays share a frequency limitation of one procedure code every five calendar years. The record shows that you received a complete series of intraoral x-rays (D0210) on November 18, 2019 and your full mouth or panoramic x-rays benefit has been exhausted. The record also shows that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and complete series of intraoral x-rays (D0210) provided on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an ultralight wheelchair (K0005), heavy duty upgrade (K0108), and accessories (E2201, E2219, E2219, E2213, E2213, E0961, E0961, K0040, K0040, E0951, E0951, K0108, E0973, E0973, E0971, E0971, E0992, E2603).  You asked the Plan to pre-approve an ultralight wheelchair, heavy duty upgrade, and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules also say that manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, and K0009) include construction of any type material, including but not limited to, titanium, carbon, or any other lightweight high strength material. Suppliers must not bill code K0108 in addition to the base wheelchair for construction materials or for a "heavy duty package."  The records indicate that the specific wheelchair requested is necessary in place of a standard wheelchair for community outings and for leading into a vehicle. The records also indicate that the supplier is requesting a heavy duty upgrade separately from the wheelchair base, which is considered unbundling and is not covered. Therefore, we decided that the Plan does not have to pre-approve an ultralight wheelchair (K0005), heavy duty upgrade (K0108), and accessories (E2201, E2219, E2219, E2213, E2213, E0961, E0961, K0040, K0040, E0951, E0951, K0108, E0973, E0973, E0971, E0971, E0992, E2603).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the dental services provided by on August 26, 2020.  

You asked the Plan to pay more for the dental services. You say that you can't get dentures or implants without extracting the teeth and the surgery was medically necessary. The Plan denied your request. The Plan says benefits are limited to $1000 per calendar year, which have already been paid.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $1,000 every calendar year for covered dental services. The Plan paid $1,000 toward the dental services provided in the 2020 calendar year, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the dental services provided by on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for anticoagulant management of a patient provided on March 29, 2021.  You asked the Plan to waive the copayment for anticoagulant management of a patient. You say that you are doing at home testing and are being charged every week. 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 specialist services provided by a level 1 specialist..   You have been asked to pay the allowed amount of $10.23, which is less than the $35 copayment for anticoagulant management of a patient. Anticoagulant management of a patient 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 anticoagulant management of a patient provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 15, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you were only there for five minutes and the provider did not even touch you. 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 $15 copayment for specialist visits.   The medical records show that you received specialist services on July 15, 2021. Therefore, you are responsible to pay the $15 copayment.   You have been asked to pay a $15 copayment for a specialist visit. A specialist 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 visit provided on July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the enrollee needs another round of rehabilitative care. The Plan denied your request. The Plan says the enrollee has n skilled nursing needs and does not require daily skilled therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at a contact guard to minimal assist level with functional mobility. There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.