Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on May 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.

Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular artery embolization to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve genicular artery embolization. You say that you would like to see this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 genicular artery embolization to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care.

You asked the Plan to pre-approve adult day care. You say that you would like reconsideration because the member requires supervision/cueing with bathing/dressing, toileting, locomotion and eating. The Plan denied your request. The Plan says adult day care is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adult day care have not been met. Specifically, adult day care is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pre-approve adult day care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 100 non-emergency trips.

You asked the Plan to pre-approve additional trips. You say that you have chronic medical issues which require frequent office visits to your primary care physician (PCP) and pulmonologist. You say that you rely on your transportation benefit. You also say that the additional trips are medically necessary. The Plan denied your request. The Plan says all of your trips have been used. The Plan says that up to 100 one-way trips are covered per calendar year. The Plan also says that the benefit has been reached.

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 a maximum of 100 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 100 non-emergency trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to LTACH.

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. 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 she is 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. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH services.

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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the records, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required
(D2950 x2).
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service
is not covered under the enrollee's 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 two
core buildups, including any pins when required (D2950 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses purchased on April 27, 2021.

You asked the Plan to pay for contact lenses. You say that you contacted the Plan every step of the way and got these contacts with approval. The Plan denied your request.

The Plan says the denial of payment for these contact lenses is correct, because these contacts were not purchased from a Plan participating provider and the routine vision benefits cannot be combined with other discounts.

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 these services when received from a Plan participating provider. 

We looked at the file and the Plan's rules. This provider is not contracted with the Plan's routine vision care network. Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses purchased on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home blood glucose monitor supplies (A4253, A4259).
You asked the Plan to pre-approve home blood glucose monitor supplies. You say that the enrollee purchased a home glucose monitor and needs supplies. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that to be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must have diabetes. We looked at the file and Medicare rules. The record does not show that the enrollee has diabetes. Based on this information, we decided that Medicare rules for coverage of home blood glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve home blood glucose monitor supplies (A4253, A4259).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections.
You asked the Plan to pre-approve paravertebral facet joint injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that injection services are 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 paravertebral facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee diagnosis of spondylosis without myelopathy or
radiculopathy, cervical region. The enrollee has had chronic neck pain since May 2021. The enrollee developed a compression fracture in her thoracic and lumbar spine a year and a half ago. The enrollee has tried physical therapy & medications. The imaging reports show 2 views of her cervical spine which demonstrate mild, chronic degenerative changes at C4-C5. At C3-C4, there is facet joint hypertrophy. Physical therapy has not helped the enrollee alleviate the pain. However, the notes do not show that pain prevents the enrollee from doing at least two age-appropriate daily activities. There is no documentation of established spinal pseudarthrosis or an implanted electrical device. The notes do not show why the enrollee is not a candidate for radiofrequency ablation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided following a
treatment of a lower jaw fracture (21470) and excision of lower jaw bone (21025).

You asked the Plan to pre-approve acute inpatient hospital care. You say that you will benefit from additional
inpatient care following these necessary procedures. The Plan denied your request. The Plan says the
procedures are medically necessary and have been approved, but it is not medically necessary for inpatient care
to be provided with these procedures.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient care are met in this case.
Our physician reviewer found based on the provided notes and stability of your condition, there is no indication
that you will require hospital services that will likely cross two midnights following these procedures.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care to be provided following a treatment of a lower
jaw fracture (21470) and excision of lower jaw bone (21025).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and
interpretation of both jaws (D0367).

You asked the Plan to pre-approve the dental service. You say that getting this x-ray will allow you to have a
treatment plant put in place for implants which would vastly improve your quality of life. You also say that you
would no longer have to worry about your dentures not fitting. The Plan denied your request. The Plan says
cone beam CT capture with interpretation 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 cone beam CT is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
cone beam computed tomography (CT) capture and interpretation of both jaws (D0367).
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pre-approve specialist services. You say that you would like to see this provider because you have stomach cancer. The Plan denied your request. The Plan says there are in-network physicians available to provide these services.
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 specialist services 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 a vacuum erection system (L7900).
You asked the Plan to pre-approve a vacuum erection system. You say that due to a history of heart attack you
cannot take erectile dysfunction medication. The Plan denied your request. The Plan says rules for coverage
have not been met because the requested item is not a benefit of Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are statutorily noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a vacuum erection system have not been met. Specifically, we have determined that your request is
for a non-covered item. Therefore, we decided that the Plan does not have to pre-approve a vacuum erection
system (L7900)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), bifocal lenses (V2203, V2204), anti-reflective coating (V2750), polycarbonate lenses (V2784) and progressive lenses (V2781) provided on April 9, 2021.

You asked the Plan to pay for eyeglass frames, bifocal lenses, anti-reflective coating, polycarbonate lenses and progressive lenses.. You say that you have an allergy to nickel and chose a more expensive eye frame made of titanium. You also say the cost should be covered by the Plan. The Plan denied your request. The Plan says the Plan's allowance benefit was exhausted, and you are responsible for the remaining balance.

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 these services when The Plan contract says you have a $100 allowance benefit to use once per calendar year to use towards the purchase of eyewear. 

We looked at the file and the Plan's rules. The records show you exhausted your $100 maximum allowed benefit on April 9, 2021. The records also show that you purchased eyeglass frames at an allowed amount of $196, bifocal lenses at an allowed amount of $128, anti-reflective coating at an allowed amount of $60, polycarbonate lenses at an allowed amount of $20 and progressive lenses at an allowed amount of $50. Your total amount due is $454 ($196 + $128 + $60 + $20 + $50 = $454). You received your total allowance amount of $100, which leaves a remaining balance that you are responsible for of $354 ($454 - $100 = $354). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, bifocal lenses, anti-reflective coating, polycarbonate lenses and progressive lenses. have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), bifocal lenses (V2203, V2204), anti-reflective coating (V2750), polycarbonate lenses (V2784) and progressive lenses (V2781) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinus augmentation (D7951) for the upper left quadrant.

You asked the Plan to pre-approve the sinus augmentation. You say that your current dentures do not fit well. You say that you are having stomach problems and cannot eat well. You say that your mouth is hurting. You also say that the teeth you do have are in bad shape. The Plan denied your request. The Plan says sinus augmentation, or a sinus lift, is specifically excluded from coverage.

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 sinus augmentation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a sinus augmentation (D7951) for the upper left quadrant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection with two or more power seating system motors (code E2311).

You asked the Plan to pre-approve electronic connection. You say that you believe that this power wheelchair with accessories would best aid the enrollee in augmenting in functional deficits and enable him to complete activities of daily living. The Plan denied your request. The Plan says the denial of authorization for this component is correct, because this wheelchair has one power function so an E2311 non-expandable controller is not appropriate. The Plan also says that they may cover a non-expandable controller for one power seating actuator, code E2310, if requested.

The Plan must follow Medicare rules. Medicare rules say that code E2310 is used for an electronic connection between a wheelchair controller and one power seating system motor, while code E2311 is used for an electronic connection between a wheelchair controller and two or more power seating motors. 

We looked at the file and Medicare rules. This wheelchair only has one power seating option; therefore, an electronic connection with code E2311 would not be appropriate for this wheelchair. Please contact the Plan for more information about the use of code E2310, which the Plan has said they may approve if requested. Based on this information, we decided that Medicare rules for coverage of electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection with two or more power seating system motors (code E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on April 13, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you received a bill and should not owe
anything for the CT scan. 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 $90
copayment for diagnostic radiology services for outpatient diagnostic tests and therapeutic services and
supplies.
You have been asked to pay a $90 copayment for a CT scan. A CT scan falls within the outpatient diagnostic
tests and therapeutic services 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 copayment
for a CT scan provided on April 13, 2021