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

We decided that the Plan does not have to pre-approve office services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office services. You say that this provider has dealt with high risk patients of this type. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.
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 office services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that your doctor, nursing, physical therapist, and occupational therapist recommended that you go to an acute inpatient rehabilitation facility so that you can get intense therapy. The Plan denied your request. The Plan says based on your condition and functional status there is not a reasonable expectation that you will require the intensive rehabilitation therapy services that are uniquely provided in acute rehabilitation.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a hip fracture in April 2021, and you have been living in your apartment with complaints of weakness. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), custom fabricated abutment (D6057), abutment supported crowns (D6058), second stage implant surgeries (D6011), an overdenture for the lower jaw (D5865) and bone replacement grafts (D6104, D7953).
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary as the enrollee has a heightened risk for dental infections and complications. The Plan denied your request. The Plan says these services are not covered by Medicare or by the enrollee's 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 pre-approve surgical placement of implant body (D6010), custom fabricated abutment (D6057), abutment supported crowns (D6058), second stage implant surgeries (D6011), an overdenture for the lower jaw (D5865) and bone replacement grafts (D6104, D7953).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation services (A0425, A0426) provided on February 14, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you did not ask for this ambulance and feel the cost should be covered by your inpatient admission fees. The Plan denied your request. The Plan says this copayment was applied 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 $310 copayment for each Medicare-covered one-way ambulance trip. 

You have been asked to pay a $310 copayment for the ambulance services. Your contract does not indicate that ambulance copayments are waived if you are admitted to the emergency department or hospital. 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 non-emergent ambulance transportation services (A0425, A0426) provided on February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body (D6010), custom fabricated abutment (D6057), abutment supported crown (D6059) and bone replacement graft (D7953) for tooth #28.

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are 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 pre-approve a surgical placement of implant body (D6010), custom fabricated abutment (D6057), abutment supported crown (D6059) and bone replacement graft (D7953) for tooth #28.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of pharmacy-dispensed medication is the responsibility of the enrollee's prescription drug plan. The Plan has also indicated that this has been approved under the enrollee's Part D plan.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Benefits for Retacrit 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve a second opinion consultation to be provided by the requested out-of-network provider. You say that you were not happy with the service that you received from a Plan specialist about your retinal vein occlusion, and you are requesting coverage for a second opinion. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion consultation to be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for non-emergency transportation.
You asked the Plan to provide coverage for non-emergency transportation. You say that non-emergency transportation is needed to get to medical appointments. You say that the enrollee has suffered from a stroke and relies on his wife for transportation, but she is not comfortable driving long distances because she is a new driver. The Plan denied your request. The Plan says he only mode of transportation Medicare covers is ambulance transportation, and then only when an ambulance is medically necessary. The Plan may only cover non-emergency transportation by ambulance if it is documented that the member's condition is such that other means of transportation could endanger their health and that transportation by ambulance is medically required. Wheelchair van or chair car transportation is specifically excluded from coverage.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. The file shows that the Plan does not cover transport in a vehicle that is not an ambulance. Therefore, we decided that the Plan does not have to provide coverage for non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate denture - mandibular (D5140).

You asked the Plan to pre-approve an immediate lower denture. You say that the dentures are necessary, and it would be a financial hardship if the Plan does not cover them. 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 immediate denture - mandibular (D5140).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850.
You asked the Plan to pre-approve Genvisc 850. The Plan denied your request. The Plan says the enrollee has not met the step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc 850. Our reviewer says that Genvisc 850 is not medically reasonable and necessary in this case. Our physician reviewer found that thee enrollee has not trialed viscosupplemental treatments such as Synvisc, Durolane, and Gelsyn-3. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Genvisc 850 is not approved as step criteria have not been 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 Genvisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. There is no documentation to support that he has had an inadequate response to conservative non-pharmacologic therapy. There is no referral or orders for physical therapy or durable medical equipment. There is no documentation of an inadequate response to analgesics. The Orthovisc is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225).
You asked the Plan to pre-approve the denture. You say that your provider says that the flexible denture will be better, and you feel this will save the Plan money in the long run. The Plan denied your request. The Plan says the specific type of denture requested 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 pre-approve a partial upper denture with a flexible base (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a dental consultation provided by an OON provider.. You say that the services are medically necessary, and you were referred to an oral surgeon. The Plan denied your request. The Plan says the services can be obtained in-network and do not meet criteria for an OON exception.

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 a dental consultation when provided by a network provider.

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of a dental consultation provided by an OON provider. have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) 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 endodontic therapy, premolar tooth (excluding final restoration) (D3320).
You asked the Plan to pre-approve nerve treatment. You say that you would like the service 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 pre-approve endodontic therapy, premolar tooth (excluding final restoration) (D3320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 23, 2021.

You asked the Plan to pay for vision services. The Plan denied your request. The Plan says your Plan does not have any out-of-network vision benefits.

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 provided by a network optical provider. 

We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the Plan's optical provider. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on January 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 35 hours of personal care services (T1019) weekly.

You asked the Plan to pre-approve custodial care. You say that the services are necessary. The Plan denied your request. The Plan says custodial care is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 35 hours of personal care services (T1019) weekly.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on July 4, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 4, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on July 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter (OTC) items, Aspirin, Band-Aids, and other reimbursable items provided on December 31, 2020.
You asked the Plan to pay for over the counter (OTC) items, Allegra D, Aspirin, Band-Aids, and other reimbursable items. You say that you indicated that you could not obtain copies, because the store only keeps copies of the receipts in their system for 30 days. You say that you requested Flex reimbursement Forms on multiple occasions prior to your submission but you did not receive for forms until the end of March of 2021 and by that time some receipts might have faded out. The Plan denied your request. The Plan says some of the items are non-covered under your Flex Benefit. It was noted that the information on the receipts that were submitted with your reimbursement request were not visible and you were asked to resubmit copies of your receipts to the Plan.
The Plan contract provides supplemental coverage for over the counter (OTC) items benefit on the Flex Benefit List. We looked at the file and the Plan's rules. The file shows that some of the items purchased are not on the Plan's Flex Benefit List and some of the receipts submitted are not visible. Therefore, we decided that the Plan does not have to pay for over the counter (OTC) items Aspirin, Band-Aids, and other reimbursable items provided on December 31, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 x 2), and abutment supported crowns (D6058 x 2).
You asked the Plan to pre-approve the dental services. You say that you had initial implant work done in December 2020 as you were advised it would be covered. You say that in June 2021 you were advised the services you received in December 2020 were not covered. You also say that you still need the crowns and supporting abutments. The Plan denied your request. The Plan says custom fabricated abutments are not listed as covered services. The Plan says that abutment supported crowns are not listed as covered services either.
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 custom fabricated abutments (D6057 x 2), and abutment supported crowns (D6058 x 2).