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

We decided that the Plan does not have to preapprove for the acute inpatient hospital care to be provided after a surgical procedure.

You asked the Plan to preapprove for acute inpatient hospital care. You say that the preapproval of inpatient admission. The Plan denied your request. The Plan says there is no documentation to support a 2 midnight stay will be necessary.

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 preapprove for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is undergoing a planned right total knee arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that the admitting physician can reasonably expect that the patient's necessary hospital care (including earlier ED and/or observation care) will include inpatient admission and span two midnights. 

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 preapprove for the acute inpatient hospital care to be provided after a surgical procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that the hearing aids should be covered because the enrollee went to a specialist and was given a prescription for them. The Plan denied your request. The Plan says no documentation of a referral or prescription for hearing aids was provided for review. These items were requested from the provider, but they were not submitted. Without a referral or prescription, the hearing aids cannot be pre-approved.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
The Plan pays for hearing aids only when they are prescribed by a licensed provider and a referral is submitted. Medical necessity criteria must be met. We looked at the file, and the Plan's rules. No prescription or referral was submitted to the Plan for review. The Plan requires a referral and/or prescription for hearing aids, and no medical documentation was provided for review. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on April 5, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
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 the interrogation device evaluation provided on April 5, 2021 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 pressure reducing mattress (E0277).

You asked the Plan to pre-approve the pressure reducing mattress.. You say that the mattress is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that the enrollee must have pressure sores or ulcers in order for this surface to be 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 pressure reducing mattress.

Our reviewer says that the requested pressure reducing surface is not medically necessary. Our physician reviewer found there is no documentation by the physician that this enrollee has any complaints or signs of a pressure sore or ulcer. The enrollee states he had severe ulcers in the past requiring wound care but has no pressure sores or ulcers currently. 

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 pressure reducing mattress. have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 pressure reducing mattress (E0277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal evaluation (D0180) provided on
May 11, 2021.
You asked the Plan to pay for the dental service. You say that this service needs to be paid. You say that you
saw your dentist in March, and they were paid for an exam even though you only had x-rays taken. You also
say that this oral exam should be covered instead. The Plan denied your request. The Plan says up to 2 routine
oral exams per year are covered. The Plan also says that the frequency limit 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 and oral exams are covered, the
frequency limit has been exceeded.
The record shows that the Plan paid for a periodontal oral exam that you received on February 25, 2021, and a
comprehensive oral evaluation that you received on March 24, 2021. Therefore, we decided that the Plan does
not have to pay for comprehensive periodontal evaluation (D0180) provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300,
E2310) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, there is no documentation that the enrollee meets Medicare
criteria for the additional power wheelchair accessory (E2310) as records report she has 3-/5 upper extremity
strength indicating adequate strength to operate the power options with their own switches. E2300 (power seat
elevation feature) is not covered by Medicare as it not primarily medical in nature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2300, E2310) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Ondansetron for the enrollee.
Benefits for this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam dental image capture (D0364) provided on March 18, 2021.
You asked the Plan to pay for the dental imaging services. You say that you were dissatisfied with the care provided and you should not owe this amount for the dental care. The Plan denied your request. The Plan says this service is not covered by your dental 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 pay for the cone beam dental image capture (D0364) provided on March 18, 2021.
Your complaint about services and information provided by a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on April 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 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 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 outpatient hospital services provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two surgical extractions (D7210) and an unspecified preventative procedure (D1999) provided on February 24, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you did not know you needed to see a network provider and feel these services should be covered. The Plan denied your request. The Plan says out-of-network dental care is not covered. This claim was processed correctly in accordance with your dental 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, items or services received from out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for two surgical extractions (D7210) and an unspecified preventative procedure (D1999) provided on February 24, 2021, by an out-of-network provider.
Your complaint about information provided when you first signed up with your Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like this claim reprocessed and paid. 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 specialist services 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 pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and fixed partial denture sectioning (D9120) provided April 14, 2021.

You asked the Plan to pay for the anesthesia and fixed partial denture sectioning. You say that the services were necessary, and you feel they should 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 pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and fixed partial denture sectioning (D9120) provided April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant, (D4341 x 4), and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says the requested dental services are not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the provided documentation indicates that there are only 3 teeth present in the upper right quadrant. Therefore, the requested code D4341 does not qualify. The reviewer found that there is no discernible bone loss in any quadrant, and as such there would be no loss of attachment that would allow for scaling of the root surfaces. Therefore, there would be no medical necessity for a requested treatment plan of scaling and root planing under D4341 in the upper left, lower left or lower right quadrants. The reviewer found that with use of the approved upper partial denture, there would be an adequate number of posterior teeth in contact as to provide for chewing. Therefore, the reviewer found that the lower partial denture is not medically reasonable or necessary either. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file indicates that there is no loss of attachment that would allow for scaling of the root surfaces in any quadrant. Additionally, the file shows that there would be an adequate number of posterior teeth in contact as to provide for chewing as the partial upper denture was approved. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant, (D4341 x 4), and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 10, 2021.

You asked the Plan to pay for an eye refraction. You say that you paid $45 at the time of the visit and were unable to provide information to the provider. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 contract also says that the plan will pay for outpatient doctor services for the diagnosis and treatment of diseases and injuries of the eye. Medicare does not cover regular eye exams for glasses or contacts. 

We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 27, 2021, to May 31, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this bill. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $365 copayment per day for days 1-5 for inpatient hospital care. Records show that you were in the hospital for 4 days. You have been asked to pay a $365 copayment per day for the inpatient hospital services, for a total of $1460. 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 inpatient hospital services you received from May 27, 2021, to May 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the brain (70553).
You asked the Plan to pre-approve a brain MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers that can perform this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 magnetic resonance imaging (MRI) scan of the brain (70553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection with RACZ for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says alternative treatment may include a cervical epidural injection if the criteria are met, physical therapy, and/or a home exercise program.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational because of a lack of randomized clinical trials. There is no imaging that supports adhesions. The request is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection with RACZ for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve car rack for your wheelchair (E1399).
You asked the Plan to pre-approve a car rack for your wheelchair. You say that you require the wheelchair rack to be able to leave your home with your vehicle. The Plan denied your request. The Plan says a wheelchair rack is not a covered item at the benefit level.
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 car rack for your wheelchair (E1399).