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

 We decided that the Plan does not have to pre-approve a referral for computed tomography angiography (CTA) of the heart for evaluation of coronary artery disease with an out-of-network provider.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says network providers must be used.  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 referral for computed tomography angiography (CTA) of the heart for evaluation of coronary artery disease with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the three resin-based composites of two surfaces (D2392 x3) provided on August 17, 2021.  
You asked the Plan to pay for the three resin-based composites of two surfaces. You say that you contacted the Plan to make sure this treating provider would accept your insurance. You also say that the Plan contacted the provider's office to confirm you would have dental coverage. The Plan denied your request. The Plan says benefits for these services 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, restorations are limited to two procedure codes per calendar year. The record shows that you received five resin-based composites on August 17, 2021, two of which were covered by the Plan at the in-network rate, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the three resin-based composites of two surfaces (D2392 x3) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the coinsurance for the outpatient dialysis services provided from July 2, 2021, to July 30, 2021.  
You asked the Plan to reduce the coinsurance for the outpatient dialysis services. You say that based on your calculations, your coinsurance should be $518.37. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for in-network Medicare-covered benefits.   
You have been asked to pay a total of $648.37 which is 20% of the allowed amount for the outpatient dialysis services. The allowed amount for each date of service is $272.00. ($272 x 20% = $54.40). ($54.40 x 11 dates of service = $598.40). You have been asked to pay $49.97 on July 30, 2021, which is less than the standard coinsurance amount. The record shows you met the maximum out-of-pocket amount on this date of service. ($598.40 + $49.97 = $648.37).  The outpatient dialysis services fall within the "Services to Treat Kidney Disease" 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 reduce the coinsurance for the outpatient dialysis services provided from July 2, 2021, to July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD), with biopsy (43239) provided on July 15, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $350 per day for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center.  You have been asked to pay $350 for the outpatient procedure provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD), with biopsy (43239) provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310).  You asked the Plan to pre-approve an alveoloplasty. You say that you need this service because you are having trouble eating. 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 pre-approve an alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 8, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the provider is a level 1 specialist. 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 $45 copayment for each specialist visit with a physician that is not identified as a level 1 provider.   The file shows that a search of the Plan provider directory does not identify the provider as a level 1 physician. Therefore, you have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall 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 office visit provided on September 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Daliresp 250mcg tablets.  You asked the Plan to pre-approve the Daliresp tablets. You say that Daliresp is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 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 Daliresp 250mcg tablets.   Benefits for the Daliresp tablets 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 pre-approve an apicoectomy - anterior (D3410), retrograde filling - per root (D3430), removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450), and incisional biopsy of oral tissue-soft (D7286).  You asked the Plan to pre-approve an apicoectomy, retrograde filling, removal of benign odontogenic cyst or tumor, and incisional biopsy. You say that these services are necessary, and you would like them to be covered. The Plan denied your request. The Plan says these services are 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 pre-approve an apicoectomy - anterior (D3410), retrograde filling - per root (D3430), removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450), and incisional biopsy of oral tissue-soft (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray and topical application of fluoride provided on July 6, 2021.  You asked the Plan to pay for the panoramic x-ray and topical application of fluoride. You say that they pushed you to do the deep cleaning and didn't know the service was not covered. You say that you were informed before you left that you did not need to pay. The Plan denied your request. The Plan says the services are not covered 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 panoramic x-ray and topical application of fluoride provided on July 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra drops 5% for the enrollee.  You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says the plan does not cover outpatient prescription drugs.  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 Xiidra drops 5% for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on October 27, 2020, to November 2, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are on a fixed income and this copayment is too high. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $225 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $225 copayment per day for days 1-7. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,575 ($225 x 7 days = $1,575). The correct copayment has been applied to the inpatient hospital services provided. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on October 27, 2020, to November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve massage therapy.  You asked the Plan to pre-approve massage therapy. 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 a covered benefit.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided September 2, 2021.  You asked the Plan to pay for the re-cement crown. You say that your dentist didn't tell you that this service would not be covered. 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 re-cement or re-bond crown (D2920) provided September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home international normalized ratio (INR) monitoring machine and supplies to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve home international normalized ratio (INR) monitoring machine and supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 home international normalized ratio (INR) monitoring machine and supplies to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says your benefit only allows 60 one-way transportation trips per calendar year.  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.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for chemotherapy  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be redirected to a 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 an out-of-network referral for chemotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 26, 2021.  You asked the Plan to pay for the limited oral evaluation (D0140). You say that you experienced very bad pain in your lower left jaw and the pain was so bad you went to urgent care. You say that you don't understand why the service was denied. The Plan denied your request. The Plan says this service is only covered once per plan year.  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 one limited oral evaluation per plan year. The Plan paid for the limited oral evaluation provided on January 12, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an EasyStand Evolv sit-to-stand device (Combination sit-to-stand frame/table system, a black molded try, flip up knee pads, two multi adjustable foot plates, two foot straps, hip supports, flat back, chest strap, accessories mounting bracket and head support.  You asked the Plan to pre-approve an EasyStand Evolv sit-to-stand device (Combination sit-to-stand frame/table system, a black molded try, flip up knee pads, two multi adjustable foot plates, two foot straps, hip supports, flat back, chest strap, accessories mounting bracket and head support. You say that you were diagnosed with Multiple Sclerosis and need the equipment for your daily living activities. The Plan denied your request. The Plan says the requested item 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. Therefore, we decided that the Plan does not have to pre-approve an EasyStand Evolv sit-to-stand device (Combination sit-to-stand frame/table system, a black molded try, flip up knee pads, two multi adjustable foot plates, two foot straps, hip supports, flat back, chest strap, accessories mounting bracket and head support.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Xiidra 5% drops.  You asked the Plan to pre-approve Xiidra. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xiidra 5% drops.   Benefits for Xiidra 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).  You asked the Plan to pre-approve a CGM. You say that the requested CGM is necessary for the enrollee to monitor their blood sugar levels. The Plan denied your request. The Plan says the coverage criteria for the CGM 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a cardiac computed tomography (CT) calcium scoring.  You asked the Plan to pre-approve a cardiac computed tomography (CT) calcium scoring. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the requesting provider is a contract provider with the Plan. We requested medical records from the last six months to be provided for review to determine if these services were necessary; however, the Plan did not provider sufficient medical records from this provider. Contract plan providers are considered agents of the plan. The Plan did not substantiate their denial with the appropriate medical records. Therefore, we decided that the Plan has to pre-approve a cardiac computed tomography (CT) calcium scoring.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.