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

We decided that the Plan does not have to pre-approve a shower chair and adult diapers.
You asked the Plan to pre-approve the items. You say that this is medically necessary to prevent you from
becoming infected. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. The Plan covers all items that Medicare covers. Medicare rules say that
shower chairs are not covered because they are not primarily medical in nature. Medicare rules state that
incontinence supplies are not covered because they are hygienic items that are non-reusable.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers
coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair and
adult diapers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick urine collection system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Purewick urine collection system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pontics (D6245 x2) and two fixed retainers (D6548 
x2). 
 
You asked the Plan to pre-approve the pontics and fixed retainers. You say that your previous bridge was 
removed because the tooth attached to it was rotten. You also say that you need a new one because you are 
having trouble eating. 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 two 
pontics (D6245 x2) and two fixed retainers (D6548 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive needed care in another setting, such as a skilled nursing facility.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 ofthe 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. Long term acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete removal of nasal sinus using an endoscope
(31255) and removal of nasal sinus tissue using an endoscope (31267).
You asked the Plan to pre-approve the complete removal of nasal sinus using an endoscope and removal of
nasal sinus tissue using an endoscope. You say that the requested surgery services are medically necessary. The
Plan denied your request. The Plan says the procedures 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 the complete removal of nasal sinus
using an endoscope and removal of nasal sinus tissue using an endoscope. Our reviewer says that the requested
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found according to the patient's history; he is not suffering from symptoms of chronic sinusitis. In addition, the
patient's history does not state that he has tried any medical treatment for his chronic sinusitis. Furthermore, the
computed tomography (CT) scan does not show evidence of ethmoid or maxillary sinus disease that warrants
surgery. Therefore, these procedures are not necessary or medically indicated.
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 complete removal of nasal sinus using an endoscope and removal of nasal
sinus tissue using an endoscope have not been met. Therefore, we decided that the Plan does not have to preapprove
the complete removal of nasal sinus using an endoscope (31255) and removal of nasal sinus tissue
using an endoscope (31267).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRituxan.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of rheumatoid arthritis. She has not tried and failed the Plan's required drug, Truxima. The records do not show that the required drug would be contraindicated or less effective; therefore, Rituxan is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveRituxan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient hospital care for the enrollee.You asked the Plan to pre-approveacute inpatient hospital care. You say that these services are medically necessary.The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. The patient appears to be medically stable. There is no information in the records that supports the need for inpatient status after surgery. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient hospital care for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for sacroiliac joint pain 
(64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this procedure is considered experimental/investigational due to the wide 
variation in efficacy reported in the medical literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation for sacroiliac joint pain (64625).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveProlia for the enrollee.You asked the Plan to pre-approveProlia. You say that this is medically necessary.The Plan denied your request. The Plan says that that the enrollee doesn't meet criteria for coverage of Prolia.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effectiveand otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is medically reasonable and necessary for the enrollee in this case. The enrollee has a history of osteoporosis. Denosumab (Prolia) is a humanized monoclonal antibody directed against the receptor activator of the nuclear factor-kappa B ligand (RANKL),which is a key mediator of the resorptive phase of bone remodeling. Denosumab decreases bone resorption by inhibiting osteoclast activity. Denosumab was approved by the FDA in 2010. It has shown benefit in cancer patients, patients with postmenopausal osteoporosis, and men with low BMD. The approved dosage is 60 mg given subcutaneously every 6 months. Denosumab may be considered in certain patients with renal insufficiency, as impaired kidney function does not significantly affect the metabolism or excretion of the drug. The documentation supports that the Prolia is safe and effective for the patient. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan has to pre-approveProlia for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa cap 1mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that the enrollee has tried and failed Omega-3-acid ethyl
esters (Lovaza) and Atorvastatin (Lipitor). 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 selfadministered
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 Vascepa cap 1mg for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for diagnostic mammography, tomosynthesis, and ultrasound provided.

You asked the Plan to waive the co payment for diagnostic imaging. You say that this was a preventive mammogram and the Plan sent you a reminder to have it done.The Plan denied your request. The Plan says the co payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 co payment for in-network basic radiology tests at an outpatient hospital. These tests were provided for a non-routine diagnosis, so they are considered to be diagnostic imaging and not screening or preventive services.

You have been asked to pay $110 co payment for diagnostic imaging. Diagnostic imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the co payment for diagnostic mammography, tomosynthesis, and ultrasound provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services with dental codes D0140, D3310, and D0364 provided on September 3, 2020 and September 9, 2020.You asked the Plan to pay forthe dental services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the dental services are not covered under your supplemental dental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D0140, D3310, and D0364 are not among those covered under this benefit. The Plan overturned their denial of payment for the filling you received with dental code D2330, leaving you responsible for the 50% coinsurance for the filling.Therefore, we decided that the Plan does not have to pay forthe dental services with dental codes D0140, D3310, and D0364 provided on September 3, 2020 and September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services (A0492-QL) provided to the enrollee on August 29, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the claim was not billed according to Medicare guidelines.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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances.  Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services (A0492-QL) provided to the enrollee on August 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursementforthe limited oral evaluation (D0140) provided on October 5, 2020.You asked the Plan to issue reimbursement forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says youhave exhausted the dental benefit for this 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. We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met.Specifically, the Plan allows for two oral examinations per calendar year. You previously received two covered oral examinations on January 9, 2020 and July 22, 2020. Therefore, we decided that the Plan does not have to issue reimbursement forthe limited oral evaluation (D0140) provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran urgent care visit provided on October 8, 2020.You asked the Plan to waive the copayment foran urgent care visit. You say that the provider didnot receive the results in time and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for urgently needed services. You have been asked to pay the allowed amount of $37.66, which is less than the $60 copayment for an urgent care visit. An urgent care visit falls within the urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran urgent care visit provided on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to provide additional reimbursement forthe seat lift mechanism. We decided that the Plan does not have to provide additional reimbursement forthe lift chair itself. You asked the Plan to provide additional reimbursement forthe seat lift mechanism. You say that you were told that this purchase would be covered, and you would only owe 20%. You feel that the plan's payment of only $23.27 is insufficient compared to the purchase price of $476.89.The Plan says that reimbursement was correctly made based on 80% coverage of the Medicare allowed amount which is $29.09 for this item.We decided that the Planhas to provide additional reimbursement forthe seat lift mechanism.Medicare rules state that seat lift mechanisms are eligible for coverage when criteria are met. Health plans are also required to make payment at the same amount as would be made by Original Medicare. In this case, the Plan did make payment for this item, attesting that criteria are deemed met. However, review of the Medicare fee schedule information for South Carolina, the Plan based its payment on the non-rural fee for one month's rental of a seat lift mechanism. The file clearly shows that this was purchased and that the item was new. Further review also shows that for durable medical equipment (DME) purposes, ZIP code 29440 is considered rural. As such, payment should be based on the DME fee amount for a new item in a rural area, or $338.27. Since you have 20% coinsurancefor DME, which you have not contested,the correctreimbursementamount would be $270.62. Therefore, we decided that the Plan has to provide additional reimbursement forthe seat lift mechanism. We also decided that the Plandoes not have to provide additional reimbursement forthe lift chair itself.The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers.The cost of this lift chair beyond the Medicare approved amount noted above is therefore not payable, as that cost is considered to be for the chair itself.Therefore, we decided that the Plan does not have to provide additional reimbursement forthe lift chair itself.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services (90834) provided on March 11, 2020 to June 30, 2020.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were non-emergent and were not pre-authorized. There were network providers available.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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 foroutpatient mental health services (90834) provided on March 11, 2020 to June 30, 2020.