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

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you suggest the enrollee receive permanent restorations on tooth #'s 8 and 10, and to replace tooth #9. The Plan denied your request. The Plan says these 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. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 19, a partial upper denture with flexible base (D5225), and a partial lower denture with flexible base (D5226).
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary. The Plan denied your request. The Plan says crown is not listed as a covered service. The Plan says that partial dentures with flexible bases are not listed as covered services either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the crown and partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 19, a partial upper denture with flexible base (D5225), and a partial lower denture with flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crowns (D6740) for teeth # 13 and 15, and the pontic (D6210) for tooth # 14.
You asked the Plan to pre-approve the bridge. You say that the bridge is necessary. The Plan denied your request. The Plan says a bridge is not 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 the retainer crowns (D6740) for teeth # 13 and 15, and the pontic (D6210) for tooth # 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010) and custom fabricated abutment - includes placement (D6057, D6058) for tooth #3.
You asked the Plan to pre-approve an endosteal implant and abutment for tooth #3. You say that you need the implant to prevent further damage. The Plan denied your request. The Plan says these services are not covered under your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant (D6010) and custom fabricated abutment - includes placement (D6057, D6058) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three extractions (D7140 x3) and a maxillary partial denture (D5213) to be rendered by an OON provider.
You asked the Plan to pre-approve the extractions and maxillary partial denture. You say that you have been under the care of this provider for a long time, and would like to continue with him. The Plan denied your request. The Plan says services provided by an OON or non-contracted provider are not provided under this benefit program. The Plan also says that there are in-network dental providers readily available and accessible to you.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve three extractions (D7140 x3) and a maxillary partial denture (D5213) to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97014) provided November 18, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the service is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 97014 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, the CPT code at issue has a status of "I" and is not valid for Medicare purposes. Based on this
information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore,
we decided that the Plan does not have to pay for therapy services (97014) provided November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Peroral Endoscopic Myotomy (POEM).
You asked the Plan to pre-approve a POEM. You say that the patient would benefit from this procedure to improve their quality of life. The Plan denied your request. The Plan says medical studies haven't proven that the service(s) or procedure(s) is helpful for treatment of your health problem.
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 POEM. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no objective data was presented with the enrollee's records that support their symptoms are medically-refractory. The enrollee is high risk for both endoscopic sedation and for procedure-related exacerbation of diarrhea. G-POEM may not at this time represent their best or safest option.
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 POEM have not been met. Specifically, the safety and efficacy of this procedure for the enrollee's symptoms are unknown. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a Peroral Endoscopic Myotomy (POEM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OPDIVO solution (J9299).
You asked the Plan to pre-approve the OPDIVO solution. You say that the drug is medically necessary. The Plan denied your request. The Plan says the efficacy is not demonstrated in peer reviewed literature for this diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 OPDIVO solution. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the use of this drug is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for the enrollee's diagnosis.
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 OPDIVO solution have not been met. Therefore, we decided that the Plan does not have to pre-approve the OPDIVO solution (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested compression stockings are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010) and a bone graft at time of implant placement (D6104).
You asked the Plan to pre-approve the endosteal implant and bone graft. The Plan denied your request. The Plan says these 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. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010) and a bone graft at time of implant placement (D6104).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visits to be provided by an OON provider.
You asked the Plan to pre-approve the home visits. You say that the enrollee has escalating behavioral and health concerns that cannot be adequately addressed by requiring that she travel to see a provider in a traditional office setting. You also say that the enrollee is increasingly combative and presents a risk to herself. The Plan denied your request. The Plan says you are not an in-network provider with the enrollee's plan. The Plan also says that there are available in-network providers that the enrollee could use for the services she wants and needs.
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 home visits to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a Continuous Positive Air Pressure (CPAP) machine (E0601).
You asked the Plan to pre-approve continued CPAP rental. You say that continued use of the CPAP is medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support the request.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Minimal medical records were provided to support this request. There is no documentation of compliance with usage and no documentation of sleep studies provided to determine if continued CPAP use is medically necessary. Based on this information, we decided that Medicare rules for coverage of continued CPAP rental have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a Continuous Positive Air Pressure (CPAP) machine (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed, a gel overlay mattress, and a manual wheelchair to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a semi-electric hospital bed, a gel overlay mattress, and a manual wheelchair. You say that your social worker told you that you need to use an OON provider. The Plan denied your request. The Plan says these items are available in-network.
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 items 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 semi-electric hospital bed, a gel overlay mattress, and a manual wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7240) for tooth #'s 1 and 16.
You asked the Plan to pre-approve the removals of impacted teeth. You say that these teeth must be removed in order for the enrollee to wear dentures. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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. Therefore, we decided that the Plan does not have to pre-approve the removal of an impacted tooth (D7240) for tooth #'s 1 and 16.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Orencia ClickJect.
You asked the Plan to pre-approve Orencia ClickJect. You say that the drug is medically necessary. The Plan
denied your request. The Plan says the Plan does not cover self-administered drugs.
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 the Orencia ClickJect.
Benefits for Orencia ClickJect 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: 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 records provided support the need for LTACH care. The Plan denied your request. The Plan says the requirements for approval of LTACH care have not been met.
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 short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110),
bitewing radiographic images (D0274), and a filling (D2150) provided from January 19, 2021, through January
20, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, bitewing radiographic images, and a
filling. You say that you were not aware the provider was out-of-network. The Plan denied your request. The
Plan says you are not covered for this service when seen by an out-of-network provider.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a periodic oral evaluation, a teeth cleaning, bitewing radiographic images, and a filling have not
been met. Specifically, services were provided by an out-of-network provider without prior authorization. The
Plan has contracted providers available to provide these services. 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 periodic oral
evaluation (D0120), a teeth cleaning (D1110), bitewing radiographic images (D0274), and a filling (D2150)
provided from January 19, 2021, through January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH services. The Plan denied your request. The Plan says the enrollee is receiving the appropriate
inpatient acute care and does not require transfer to 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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not. medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is unlikely to tolerate 3 hours of intensive daily therapy.
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 physician reviewer found that the enrollee has a past medical history of hip arthroplasty and is living at home. She is receiving home health physical therapy. Her medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services for assistance with laundry (T1019).
You asked the Plan to pre-approve the personal care services. You say that you need help because you are unable to use your hands like you were able to prior to your surgery. The Plan denied your request. The Plan says you are requesting household assistance to do your laundry, which is not a covered benefit.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal care services for assistance with laundry (T1019).