Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).

You asked the Plan to pre-approve an automatic blood pressure monitor. You say that the requested item is a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for an automatic blood
pressure monitor have not been met.

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. The requested item
is designated by Medicare as preventive. Medicare does not provide coverage for preventive services.
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor
(A4670).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo 100mg/10ml vial for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is for MSI-H or dMMR type colorectal cancer that has spread beyond its original site.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found per the NCCN compendia, this drug is approvable before AP resection, or as second line chemotherapy. The criteria is not 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo 100mg/10ml vial for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.

You asked the Plan to pre-approve Crutch substitute, lower leg platform, with or without wheels, each (E0118). You say that you doctor says it is medically necessary for you to have a knee scooter. The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness to establish the medical necessity for this product.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Knee scooters are statutorily excluded by Medicare. Based on this information, we decided that Medicare rules for coverage of Crutch substitute, lower leg platform, with or without wheels, each (E0118) have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network
provider at the in-network benefit level.

You asked the Plan to pre-approve the physical therapy to be provided at the in-network benefit level. The Plan
denied your request. The Plan says that under your Plan, you would have to see this provider using your out-of-network
benefits as explained in your EOC, as there are in-network providers in the region with no evidence
that in-network specialist resources in the same geography to you have been exhausted. There are over 100 in-network
physical therapist in your geographic area, therefore, there are no in-network inadequacies.

The Plan contract says the Plan covers outpatient Medicare-covered therapy visits at 50% of the Medicare-allowed
amount for each physical, speech or occupational therapy visit when you get these services out-of-network.

We looked at the file and the Plan's rules. The file shows that coverage for outpatient physical therapy with an
out-of-network provider is covered at 50% of the Medicare allowed amount for each therapy visit. The file
shows that you would have to use your out-of-network benefits to see the requested provider. Therefore, we
decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network
provider at the in-network benefit level.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a permanent placement of a neurostimulator electrode array.

You asked the Plan to pre-approve Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed (64561) and Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) (64581). You say that the enrollee did not have a chance to complete the first trial stage. The Plan denied your request. The Plan says there was not a successful trial.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The trial was not successful. Based on this information, we decided that Medicare rules for coverage of Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed (64561) and Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) (64581) have not been met. Therefore, we decided that the Plan does not have to pre-approve a permanent placement of a neurostimulator electrode array.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 genetic testing.

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 testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that F5 genetic testing is non-covered except for in pregnant patients.

We looked at the file and Medicare rules. The file shows that the F5 genetic testing is not being requested for a pregnant patient. This testing is non-covered by Medicare outside of this indication. Therefore, we decided that the Plan does not have to pre-approve F5 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioimpedance spectroscopy.

You asked the Plan to pre-approve Bioimpedance spectroscopy (BIS), extracellular fluid analysis for
lymphedema assessment(s) (93702). You say that recent research shows that bioimpedance devises are
supported. The Plan denied your request. The Plan says medical literature does not support that this
measurement is the standard of care for the diagnosis of lymphedema.

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 Bioimpedance spectroscopy (BIS),
extracellular fluid analysis for lymphedema assessment(s) (93702). Our reviewer says that the requested
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the clinical documentation does not support that Bioimpedance spectroscopy, extracellular fluid analysis
for lymphedema assessment, is medically reasonable and necessary for the enrollee in this case. It is
documented that the enrollee has no lymphedema of her arm. Furthermore, the evidence that Bioimpedance
spectroscopy is clinically useful is not conclusive.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema
assessment(s) (93702) have not been met. Therefore, we decided that the Plan does not have to pre-approve
Bioimpedance spectroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 11, 2021 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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 are responsible for a 50% coinsurance for each service plus the difference between the billed amounts and allowed amounts. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 11, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar sacral orthosis (L0648) provided on December 13, 2020.

You asked the Plan to pay for a lumbar sacral orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a lumbar sacral orthosis have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a lumbar sacral orthosis (L0648) provided on December 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on December 10, 2019.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the hearing aids were purchased outside of the Plan's hearing aid provider network.

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 you see the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on December 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech therapy to be provided by the out-of-network provider.

You asked the Plan to pre-approve the speech therapy to be provided by the out-of-network provider. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered.

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 speech therapy to be provided by the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bicalutamide 50mg tablets.

You asked the Plan to pre-approve the Bicalutamide tablets. You say that this drug is necessary to treat the enrollee's condition. The Plan denied your request. The Plan says this oral drug cannot be covered by Medicare 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 Bicalutamide 50mg tablets.

Benefits for the Bicalutamide 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 gingival irrigation (D4921) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that you cannot walk up and down your stairs. The
Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 2 and 3.

You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 2 and 3.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lumbar or sacral spine (64635, 64636).

You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says the Medicare-mandated frequency limitation for a radiofrequency ablation has been met.

The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiofrequency ablation have not been met. Specifically, the record shows that the enrollee had two previous lumbar radiofrequency sessions on June 9 and June 30, 2020. The enrollee is not eligible for another lumbar radiofrequency session until June 10, 2021. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lumbar or sacral spine (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Biovance per square centimeter.

You asked the Plan to pre-approve Biovance per square centimeter. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 Biovance per square centimeter. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation is insufficient to establish the medical necessity and reasonableness of the requested service as defined by Medicare rules. The elements of the coverage rules are not satisfied. The requested service cannot be recommended at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Biovance per square centimeter have not been met. Therefore, we decided that the Plan does not have to pre-approve Biovance per square centimeter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiofrequency Facet Ablations.

You asked the Plan to pre-approve Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635), Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636). You say that you do the procedures unilaterally so it should only be counted as having it done twice per year. The Plan denied your request. The Plan says the enrollee is not eligible for more sessions.

The Plan must follow Medicare rules. Medicare rules say that that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. It has not been 12 months since the last sessions. Based on this information, we decided that Medicare rules for coverage of Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635), Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636) have not been met. Therefore, we decided that the Plan does not have to pre-approve Radiofrequency Facet Ablations.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications. The enrollee had stable vital signs. The enrollee used oxygen via nasal cannula. The enrollee required supervision to minimal assistance for functional mobility including walking to 10 feet with a rolling walker. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that the enrollee requires skilled nursing or therapy services on a daily basis. The enrollee's care needs can be met 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit.

You asked the Plan to pre-approve a transit kit. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a transit kit is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit kit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for ambulance services provided by a participating provider on November 25, 2020, to November 26, 2020.

You asked the Plan to waive the co-payment for ambulance services. You say that you do not agree with these co-payments. The Plan denied your request. The Plan says the correct co-payments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 co-payment for ambulance services/Southern California Region.

You have been asked to pay a $200 co-payment and a $187.30 co-payment for ambulance services. The total amount you are being asked to pay is $387.30 ($200 + $187.30 = $387.30). The correct co-payments have been applied. Ambulance services fall within the ambulance services/Southern California Region 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 co-payment for ambulance services provided by a participating provider on November 25, 2020, to November 26, 2020.