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

We decided that the Plan does not have to pre-approve a Cardiomems system for the enrollee.
You asked the Plan to pre-approve a Cardiomems system. You say that the enrollee would benefit from this. The Plan denied your request. The Plan says that this is not covered.
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 a Cardiomems system. Our reviewer says that a Cardiomems system is not considered medically reasonable and necessary in this case. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that Medicare coverage criteria are not met since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Cardiomems system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cardiomems system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

We decided that the Plan does not have to pay for CPT code 99253 provided on September 27, 2019.
You asked the Plan to pay for CPT code 99253. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 99253 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for CPT code 99253 provided on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and evaluation services rendered on November 7, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that procedure codes 99215 and 99354 were not billed with an appropriate primary diagnosis code. 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 pay for the office visit and evaluation services rendered on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from June 25, 2019 to December 20, 2019.
You asked the Plan to pay for the dental services. You say that these services were provided due to a medical situation, not for cosmetic purposes. You also say that you feel the services should be covered under your medical insurance. The Plan denied your request. The Plan says your annual benefit limit had been reached.
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, these services meet the Medicare definition of dental services as they involve the care, treatment, replacement, etc. of the teeth and supporting structures. These services were no longer for the treatment of the jaw fracture. The Plan offers a $650 annual dental benefit maximum. The record shows that you met the annual maximum benefit and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the dental services provided from June 25, 2019 to December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 17, 2020 to February 12, 2020.You asked the Plan to pay for the self-administered drugs. You say that you do not understand why these drugs are not covered.The Plan denied your request. The Plan says the drugs provided were self-administered. The Plan also says that these services are not included in Part A or Part B 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 pay for the self-administered drugs provided from January 17, 2020 to February 12, 2020.Benefits for the self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that because of your medical condition a shower bench is necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower chair.
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 has complex medical needs.The Plan denied your request. The Plan says it is not clear the enrollee would improve in an LTACH.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 patient is currently undergoing treatment at an acute care hospital (ACH).  The enrollee received a tracheotomy and remains on a ventilator. There is no evidence that weaning has been actively ongoing, and it is noted that the enrollee is not expected to be weanable for several months. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit that you provided on December 10, 2019. You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary, rest home visit that you provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve a breast prosthesis and bra (L8000, L8030). You asked the Plan to pre-approve a breast prosthesis and bra. You say that the requested items are medically necessary due to scoliosis. The Plan denied your request. The Plan says rules for coverage have not been met. The Plan must follow Medicare rules. Medicare rules say that a breast prosthesis and bra is covered for a patient who has had a mastectomy. We looked at the file and Medicare rules. The record shows no history of mastectomy. Based on this information, we decided that Medicare rules for coverage of a breast prosthesis and bra have not been met. Therefore, we decided that the Plan does not have to pre-approve a breast prosthesis and bra (L8000, L8030).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 motion orthotic device (L8702).
You asked the Plan to pre-approve MyoPro 2 motion orthotic device. You say that the enrollee needs this to control her arm. 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 MyoPro 2 motion orthotic device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found wrist/hand myoelectric components are experimental/investigational and not strongly supported above other methods for this enrollee's injury. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro 2 motion orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 motion orthotic device (L8702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alrex eye drops 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 Alrex eye drops 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 pre-approve core buildup, including any pins when required (D2950), for the enrollee.You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that the enrollee would be best served in an LTACH facility.The Plandenied your request. The Plansaysthere is no clinical advantage to LTACH over continued stay in the short term acute care 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 patient is currently undergoing treatment at an ACH, having initially been admitted with a fractured hip. Her post-operative course was complicated by a wound infection and behavioral issues. The enrollee is not intubated/ventilated. Thereis no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the currentACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveComputed Tomography (CT) of the Abdomen and Pelvis (74176)and CT of the Chest (71250).You asked the Plan to pre-approvethe CT scans. You say that the CT scans are medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the CT scans. Our reviewer says that the requested CT scans are not medically necessary. Our physician reviewer found regarding the CT of the abdomen/pelvis, guidelines support a CT urogram every two years for10 years for the surveillance of superficial and minimally invasive transitional cell carcinoma. The clinical information reviewed shows that the same test or one similar to the requested study was previously performed on September 9, 2019. The clinical information provided does not indicate a need for new imaging yet. Regarding the CT scan of the chest, a CT scan of the chest was performed on September 5, 2019 which demonstrated no metastatic disease in the chest. The clinical information provided does not describe signs or symptoms of disease involving the chest or a new or worsening abnormality on a recent chest x-ray. Routine chest imaging of asymptomatic patients is not supported for this malignancy without prior chest involvement or new abnormality onchest x-ray.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 CT scans have not been met.Therefore, we decided that the Plan does not have to pre-approveComputed Tomography (CT) of the Abdomen and Pelvis (74176) and CT of the Chest (71250).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on December 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on December 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346), crown - porcelain fused to high noble metal (D2750), core buildup, including any pins when required (D2950) and clinical crown lengthening - hard tissue (D4249).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the 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, the requested items or services are not among those covered under this benefit. Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346) and clinical crown lengthening - hard tissue (D4249) are not listed in your EOC as covered benefits. Furthermore, Crown - Porcelain Fused To High Noble Metal Tooth # 19 (D2750) and Core Buildup, Including Any Pins when Required Tooth # 19 (D2950) are covered once every 5 years under the benefit plan. These codes were completed on May 17, 2018. Therefore, we decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation (D4346), crown - porcelain fused to high noble metal (D2750), core buildup, including any pins when required (D2950) and clinical crown lengthening - hard tissue (D4249).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is not ready to go home. The
appellant says that if the enrollee goes home it is possible he will be readmitted. The Plan denied your request.
The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can
receive the needed care in another setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and
ophthalmic medications. The enrollee had stable vital signs, was treated for pain with effect, was alert, was
forgetful, and had clear lungs. The enrollee received physical therapy, speech therapy, and occupational therapy
in the acute hospital. The enrollee was at an independent to supervision level with functional mobility,
including gait to 150 feet with a rolling walker. The enrollee required varying assist with activities of daily
living. The enrollee had cognitive impairment. There are no identifiable skilled nursing service needs. There
are identifiable skilled therapy service needs, but they are not required on a daily basis.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. You say that you have been seeing this physician until he left the medical group and you would like to continue seeing him because he has kept you alive for three years and you do not wish to change physicians. The Plan denied your request. The Plan says the Plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty network.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 contract with the Plan also says that your plan requires you to receive care from providers who are part of your primary care physician's (PCP) medical group network.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 the requested physician's services.