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

We decided that the Plan does not have to pre-approve continued rental of a home ventilator.
You asked the Plan to pre-approve continued rental of a home ventilator (E0466). You say that the enrollee needs the home ventilator. The Plan denied your request. The Plan says there is no indication the enrollee has used the device since September 2019.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file and Medicare rules. There is no record of recent utilization or benefit. Based on this information, we decided that Medicare rules for coverage of continued rental of a home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee is not a good candidate for an invasive surgical procedure. The Plan denied your request. The Plan says the device is only indicated for patients with mild to moderate stenosis.
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 requested services. Our physician reviewer found that the requested device remains experimental at this time. More research is needed to show safety and efficacy. Therefore, the requested interspinous spacer is not considered medically reasonable and necessary 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 10, 2019 to July 19,
2019 by the out of network provider.
You asked the Plan to pay for psychotherapy visits. You say that you are treating this enrollee's conditions and
request payment for these claims. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because this provider is out-of-network with the Plan and prior authorization was not
obtained.
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 has network providers
available who can provide 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 medical services provided on May 10, 2019 to
July 19, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the incisional biopsy of oral tissue.
You asked the Plan to pre-approve the biopsy. You say that this biopsy is very important for you to get due to having half of your kidney removed from cancer. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 incisional biopsy of oral tissue.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Flexitouch pneumatic compression device and lower garments. You asked the Plan to providea pneumatic compression device (E0652) and lower garments. You say that the enrollee tried a regular leg pump device with poor results.The Plan denied your request. The Plan says the enrollee did not try a standard pump for 4 weeks.The Plan follows Medicare rules. The rules state that a PCD coded as E0652is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to providea Flexitouch pneumatic compression device and lower garments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Breast prosthesis, mastectomy form (L8020).
You asked the Plan to pre-approve the prosthesis. You say that the 2 forms are different as one is cloth for this time after surgery while the wound is tender and healing and for leisure and the other would be silicone and more suitable as you heal. The Plan denied your request. The Plan says per the LCD, more than one external breast prosthesis per side is non-covered.
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. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve Breast prosthesis, mastectomy form (L8020).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care (99233) provided on February 14, 2018 to February 16, 2018
You asked the Plan to pay for hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 has network providers available who can provide 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 hospital care (99233) provided on February 14, 2018 to February 16, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.
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 an injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered 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 Entyvio (J3380).
Benefits for Entyvio 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 tertiary level of care office visit for the enrollee.
You asked the Plan to pre-approve tertiary services. The Plan denied your request. The Plan says a pre-op
evaluation is within the scope of practice of community level internal medicine.
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 tertiary services. Our physician
reviewer found that the enrollee presents with complaints of 1-year history of progressive right hip pain. The
enrollee requires surgery on both the right proximal femur and right tibia. Based on the records provided, a
tertiary level of care is not medically reasonable and necessary to treat the enrollee prior to surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of tertiary services have not been met. Therefore, we decided that the Plan does
not have to pre-approve a tertiary level of care office visit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 19, 2019.
You asked the Plan to pay for the physician's services. You say that this physician performed your transplant and you went to see this provider because there is no cornea specialist in an emergency room or an urgent care center. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file, and Medicare rules. The file shows that the services you received were not due to an unforeseen condition or illness. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown for tooth #5.
You asked the Plan to pre-approve the crown. You say that you had a root canal done but the crown fell off and you would like to have it fixed. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, porcelain/stainless steel crowns are covered once per 60 months per tooth. The record shows that you received a crown for tooth #5 on May 15, 2019 and your porcelain/stainless steel crowns benefit for tooth #5 is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown for tooth #5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics and related services.
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics and related services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for the specialist office visit provided on June 20, 2019.
You asked the Plan to reduce the deductible for the specialist office visit. You say that at the time of service, the provider was out-of-network. You say you would like the claim reconsidered because as of September 1, 2019, the provider is now in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible that applies towards out-of-network specialist. The specialist office visit you asked the Plan to reduce the deductible for falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards out-of-network specialist visit. The allowed amount for the specialist office visit is $142.28. Therefore, $142.28 was applied to the out-of-network deductible.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on June 20, 2019. Therefore, we decided that the Plan does not have to reduce the deductible for the specialist office visit provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic parenteral drugs, inhalation of nitrous oxide/analgesia, first 15 minutes of IV moderate sedation/analgesia, and each subsequent 15 minute increment of IV moderate sedation/analgesia.
You asked the Plan to pre-approve the therapeutic parenteral drugs, inhalation of nitrous oxide/analgesia, and IV moderate sedation/analgesia services. You say that you need to get your 4 wisdom teeth removed because you have been in a lot of pain. You also say that you cannot pay for these services. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 therapeutic parenteral drugs, inhalation of nitrous oxide/analgesia, first 15 minutes of IV moderate sedation/analgesia, and each subsequent 15 minute increment of IV moderate sedation/analgesia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular overdenture.
You asked the Plan to pre-approve the complete mandibular overdenture. You say that you need overdentures because you have implants and regular lower dentures will not fit. You also say that overdentures are medically necessary for you. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.
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 complete mandibular overdenture.
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 enrollee will require 3-4 weeks for continued vent weaning and to transition from her acute illness. The Plan denied your request. The Plan says the information provided does not show that the enrollee meets the guidelines for coverage of LTACH care. The plan says that the enrollee's care can be provided in the current inpatient hospital.
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 the enrollee's ongoing care needs include tracheostomy care and ventilator support with weaning trials, nebulizer treatments, surveillance laboratory studies, tube feedings, sacral wound care, and therapy services. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee cannot tolerate intense levels of rehab.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may be more appropriate. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 10, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is not valid referral for 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 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the requested orthotics are for varicose veins, neuropathy and a genetic foot deformity. You say that you also have tendonitis and fasciitis in your feet and that the orthotics are a necessity for you. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the reline of a complete maxillary denture (D5730), and the implant services (D6199) provided from July 23, 2019 to August 6, 2019 by the facility.
You asked the Plan to reimburse you for the dental services. The Plan denied your request. The Plan says implant 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, implant services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the reline of a complete maxillary denture (D5730), and the implant services (D6199) provided from July 23, 2019 to August 6, 2019 by the facility.