Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs.  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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).  You asked the Plan to pre-approve the special supplemental benefits. The Plan denied your request. The Plan says you do not meet the required criteria that make you eligible for these special supplementary benefits.  The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture (D5214).  You asked the Plan to pre-approve the denture. You say that this denture is necessary and needs to be replaced. The Plan denied your request. The Plan says this enrollee received a previous partial lower denture (D5214) in April of 2017, which was covered by the Plan at that time. It has been less than 5 calendar years since the previous denture was covered, and therefore the enrollee's benefit for a lower denture has been exhausted.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one set of complete or partial dentures per arch every five calendar years.  We looked at the file and Medicare rules. Documentation shows that the Plan has paid for a previous lower denture for this enrollee less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from August 7, 2021, through August 9, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were taken by ambulance to the emergency room. You say that you had to be hospitalized and are appealing the denial of medical services. The Plan denied your request. The Plan says these services may be covered under your Part D plan.   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 pay for the self-administered drugs provided from August 7, 2021, through August 9, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF is in your best interests. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. You continue to have a need for skilled therapy but can receive services 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 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 pay for the intraoral x-ray provided on June 29, 2021, and periodontal scaling and root planing provided on August 4, 2021, from an out-of-network provider.  You asked the Plan to pay for the intraoral x-ray and periodontal scaling and root planing. You say that you already paid $73 for x-rays. The Plan denied your request. The Plan says out-of-network dental services are 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided on June 29, 2021, and periodontal scaling and root planing provided on August 4, 2021, from an out-of-network 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 you have used 24 of the 24 trips and have 0 trips remaining in 2021.  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 24 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 provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.  You asked the Plan to pre-approve the extra benefits. You say that these benefits/services would be beneficial to you. The Plan denied your request. The Plan says you do not meet the criteria to qualify for this supplemental benefits package.  The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the extra benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.  You asked the Plan to pre-approve coverage for special supplemental benefits. The Plan denied your request. The Plan says you do not meet the criteria established to receive the special supplemental benefits.  The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6062).  You asked the Plan to pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6062). You say that you need a crown for tooth #19. 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 pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6062).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the complete upper denture rebase (D5710).  You asked the Plan to pre-approve the complete upper denture rebase (D5710). You say that a rebase would fix the denture base that was damaged rather than changing the whole top denture. The Plan denied your request. The Plan says the service is not a covered benefit.  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 the complete upper denture rebase (D5710).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Roho cushion.  You asked the Plan to pre-approve a Roho cushion. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that the rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands).  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Roho cushion. Our reviewer says that the item is not medically necessary. Our physician reviewer found the requested ROHO seat cushion is not medically necessary per Medicare Managed Care Manual Chapter 4, Section 10.12.2. The documentation does not reveal that you require the ROHO brand seat cushion to meet your medical needs over a standard non brand specific seat cushion.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Roho cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a Roho cushion.
Appeal type: Supplemental Benefit
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 you have used 24 of the 24 trips and have 0 trips remaining in 2021.  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 24 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 provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), resin-based fillings (D2332, D2335, D2394) and unspecified preventative procedure (D1999) provided on July 10, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network dental care. You say that you believed all of these services would be covered in full. The Plan denied your request. The Plan says this claim was processed correctly. These services were received from an out-of-network provider. There is no coverage for unspecified preventative procedures. The Plan has paid the allowed rate for the comprehensive oral exam and two of the fillings, but you are responsible for the difference between the Plan's payment and the amount the provider billed. The remaining fillings exceeded the frequency limitations of your benefit for the year and will not be 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. The Plan covers some dental services, which may also be subject to limitations in frequency. The Plan can cover up to two fillings per year. You may receive care from in-network or out-of-network providers. All covered dental services are listed with 0% coinsurance on the Plan's allowed cost for services. Network dentists have agreed to provide services at this negotiated rate. If you see a network dentist, you cannot be billed more than this rate for covered services. Benefits received out-of-network are subject to any in-network benefit maximums, limitations and/or exclusions. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.    On the date in question, you received a comprehensive oral exam, four fillings, and an unspecified preventative procedure. Documentation shows that the Plan paid the full allowed rate for the comprehensive exam and two of the four fillings. Documentation also shows that the provider in this case is an out-of-network provider. You are being asked to pay the difference between the Plan's allowed amount for the covered exam and fillings and the amount billed by the provider. This means that you have been asked to pay the correct amount for these services based on your contract with the Plan. The two additional fillings are not covered, as they exceed the Plan's frequency limitation. The unspecified preventative procedure is also not covered, as it is not listed as an eligible service in the Plan's contract. Therefore, we decided that the Plan does not have to pay any additional amount for the comprehensive oral evaluation (D0150), resin-based fillings (D2332, D2335, D2394) and unspecified preventative procedure (D1999) provided on July 10, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.  You asked the Plan to pre-approve a Freestyle Libre. You say that the requested item has helped you successfully control your condition for two years without medication. The Plan denied your request. The Plan says rules for continuous glucose monitors have 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 you do not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on June 29, 2021.  You asked the Plan to waive the copayment for the EKG. You say that this should be included in the cost of the office visit. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($14.80) is less than your copayment obligation, you are responsible for the full allowed 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 diagnostic procedures and tests.   You have been asked to pay a $35 copayment for the EKG. The EKG falls within the diagnostic procedures and tests benefit category. Plans are permitted to charge separate cost sharing for diagnostic tests you receive in your doctor's office. 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 electrocardiogram (EKG) you had on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve the oral appliance.  You asked the Plan to pre-approve the oral appliance. You say that you would like reconsideration because the requested appliance is medically necessary. The Plan denied your request. The Plan says that the member does not meet coverage criteria for the requested appliance.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the oral appliance. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this member has mild Obstructive Sleep Apnea with an Apnea Hypopnea Index of 5.6. The member has excessive daytime sleepiness and loud snoring. He is unable to tolerate CPAP.  There are no dental problems or TMJ disease that would preclude use of the device. All criteria for the oral appliance are met.  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 oral appliance have been met. Therefore, we decided that the Plan has to pre-approve the oral appliance.   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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional non-emergency routine transportation trips.  You asked the Plan to provide coverage for additional non-emergency routine transportation trips. The Plan denied your request. The Plan says the evidence shows the enrollee has used eighteen (18) one-way trips of the twenty-four (24) one-way trips covered by his health plan for the year 2021. The enrollee has six (6) one-way trips available. 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 non-emergency routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve these services. You say that your current unit won't hold a charge. The Plan denied your request. The Plan says the services are not covered for purchase.  The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 monthly rental payments.  We looked at the file and Medicare rules. The file shows that you are requesting a portable oxygen concentrator for purchase, not rental. Medicare does not cover the purchase of this equipment. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.