Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and dental extraction to be provided by an oral surgeon.
You asked the Plan to pre-approve a consultation and dental extraction to be provided by an oral surgeon. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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. The Plan only covers dental services when provided by a general dentist, not an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a consultation and dental extraction to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism and chair.

You asked the Plan to pre-approve a seat lift mechanism and chair. You say that this seat lift and chair are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met for the mechanism and the chair itself is not covered by Medicare for any reason.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed are met. 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 seat lift mechanism and chair. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the documentation does not show evidence of severe arthritis of the hip or knee or a severe neuromuscular disease. The documentation does not show you are completely unable to stand up from a regular armchair or any chair in the home. Medicare coverage criteria are 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 a seat lift mechanism and chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism and chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids.

You asked the Plan to pay for the hearing aids. You say that you had a $500 benefit for hearing aids. The Plan denied your request. The Plan says the benefits were applied correctly.

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.

We looked at the file, and the Plan's rules. The file shows that the total cost for the hearing aids was $1850. The plan paid $500 as per the plan benefits. Because the hearing aids cost more than $500, you are responsible for the difference. Therefore, we decided that the Plan does not have to further pay for the hearing aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction of teeth #8, 9, 10, 11, 12, and 13 (D7210).

You asked the Plan to pre-approve extraction of teeth #8, 9, 10, 11, 12, and 13. You say that the services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

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 three non-surgical or surgical extractions per calendar.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extraction of teeth #8, 9, 10, 11, 12, and 13 have not been met. Therefore, we decided that the Plan does not have to pre-approve extraction of teeth #8, 9, 10, 11, 12, and 13 (D7210).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on October 15, 2020.
You asked the Plan to pay for the echocardiography. 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 echocardiography. 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 an echocardiography provided on October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 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 you were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need rehab. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital for lower extremity weakness. Your medical problems are stable and you have no complex nursing or rehab needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehab program 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The
Plan denied your request. The Plan says rules for IRF care have not been met.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the
patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that
this patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to a non-Plan provider.
You asked the Plan to pre-approve these services. You say that you have not always been able to get accommodating vehicles for your transportation preferences. The Plan denied your request. The Plan says trips to non-Plan providers are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation for up to 16 one-way trips to plan-approved locations every year. We looked at your request, the records in the case file, and the rules. The file shows that you are requesting transportation to a non-Plan provider. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation to a non-Plan provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion or replacement of permanent cardiac
contractility modulation system (0408T).
You asked the Plan to pre-approve the insertion or replacement of permanent cardiac contractility modulation
system. You say that this service is medically necessary for the enrollee's condition. The Plan denied your
request. The Plan says medical studies have not proven that the device is helpful for the enrollee's condition.
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 insertion or replacement of
permanent cardiac contractility modulation system. Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found as the patient has no
moderate or severe heart failure symptoms or signs at present based on the most recent notes and the device
request letter, along with a very good recent clinical response to guideline directed medical therapy with
marked EF improvement, and most particularly the fact that the patient does not currently have the FDA
approved clinical indications for its use (1), the requested device would not be considered medically necessary
or appropriate in the current clinical situation.
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 insertion or replacement of permanent cardiac contractility modulation
system have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion or
replacement of permanent cardiac contractility modulation system (0408T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve radiation therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network provider.
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 radiation therapy to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of stabilizing or separating device into lower spine at single level.

You asked the Plan to pre-approve spinous process stabilizing device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 spinous process stabilizing device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis. There is no spinal instability demonstrated by flexion and extension x-rays in this case. The spinous process stabilizing device remains experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinous process stabilizing device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of stabilizing or separating device into lower spine at single level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Group 3 power wheelchair with power seat options
(E2300, K0108, K0108).
You asked the Plan to preapprove the Group 3 power wheelchair. You say that a new wheelchair is required
due to the height and wear on the current chair. The Plan denied your request. The Plan says you do not have a
qualifying diagnosis causing mobility limitation for which K0861 Group 3 power wheelchair is medically
needed.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. The plan has indicated that a Group 2 power mobility device that meets the
enrollee's needs and Medicare Rules could be reviewed if submitted. Therefore, we decided that the Plan does
not have to preapprove a Group 3 power wheelchair with power seat options (E2300, K0108, K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320).
You asked the Plan to pre-approve endodontic therapy. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3320).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment or appropriate telecommunications services.

There were no services found for member billed on service date presented in the documents by the supplier or provider. The Plan has concluded the claim should be denied due to the patient not receiving a video or telephonic visit by the ordering physician in order to warrant the code(s) billed. Furthermore, there are no claims on file with the ordering physician listed in the member's claims history from 2019 to the present.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services exceed your benefit limit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from August 24, 2020 to
March 16, 2021. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-Plan provider.

You asked the Plan to pre-approve these services. You say that you have been seeing the enrollee. The Plan denied your request. The Plan says the services are available from network providers.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve a referral to a non-Plan provider.