Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mycophenolic Acid.

You asked the Plan to pre-approve a tier exception for Mycophenolic Acid. You say that the exception is
needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.

The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a tier exception for Mycophenolic Acid have not been met. Specifically, the requested drug is
covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs
are not subject to tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier
exception for Mycophenolic Acid.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 the enrollee received 100 days of SNF care during the benefit period from September 30, 2020 to February 16, 2021. The Plan has covered 100 days of SNF care. 

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for CPAP and supplies (A4604, A7032, A7034, A7035, A7036, A7038, A7039). You say that you have limited income and would like to appeal the denial of payment. The Plan denied your request. The Plan says these services were not urgent or emergent, nor were they approved in advance. The provider is not 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided. from April 4, 2020, to April 5, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 4, 2020 to April 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided from April 4, 2020, to April 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 16, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 16, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services on May 15, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services on May 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 11, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 11, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided On September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses to be purchased.
You asked the Plan to pre-approve eyeglasses. You say that you would like to purchase glasses
because the in-network provider would need to send your frames to a lab. The Plan denied your request. The
Plan says eyeglasses are covered only from in-network providers.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one pair of eyeglasses every 2 years from participating network providers.
We looked at the file and the Plan's rules. The provider you have requested is not a participating network
provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been
met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses to be purchased.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a lower partial denture.
You asked the Plan to pre-approve the lower partial. You say that you believe that this should be covered. The Plan denied your request. The Plan says that with the approved upper denture, you will have sufficient points of contact of upper and lower teeth for functionality. A lower partial denture is not necessary.
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 the lower partial when the services are medically necessary and reasonable. 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 lower partial. Our reviewer says that the requested lower partial denture appears to be reasonable and necessary for this enrollee. Our physician reviewer found a review of the patient's dental record and radiographs indicate that an upper removable partial denture (D5213) was approved. The patient is missing mandibular posterior teeth along with a missing mandibular anterior tooth. Our dentist finds that replacement of the missing mandibular teeth is reasonable and necessary for masticatory function, occlusal stability, and aesthetics. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the lower partial have been met. Therefore, we decided that the Plan has to pre-approve a lower partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo false teeth for bridge, plastic and high gold content cap for bridge, and three white glass with high gold content cap for bridge.You asked the Plan to pre-approvetwo false teeth for bridge, plastic and high gold content cap for bridge, and three white glass with high gold content cap for bridge. 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.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 two false teeth for bridge, plastic and high gold content cap for bridge, and three white glass with high gold content cap for bridge when the services are medically necessary and reasonable. 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 two false teeth for bridge, plastic and high gold content cap for bridge, and three white glass with high gold content cap for bridge. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found a review of your dental record and radiographs indicate the presence of a bridge replacing tooth #8. There was no indication in the record as to why this bridge was to be replaced. Tooth #5 is a posterior tooth, therefore does not meet the criteria for coverage for a fixed bridge. Therefore, you do 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 the Plan's rules for coverage of two false teeth for bridge, plastic and high gold content cap for bridge, and three white glass with high gold content cap for bridge have not been met.Therefore, we decided that the Plan does not have to pre-approvetwo false teeth for bridge, plastic and high gold content cap for bridge, and three white glass with high gold content cap for bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on August 24, 2020.
You asked the Plan to pay for the vision services. You say that these services should be covered. The Plan denied your request. The Plan says that these services were not obtained from a network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided. We looked at the file and the Plan's rules. These services were not provided. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided on August 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis confirmed with imaging. She has failed conservative treatment and has had prior treatment with an intra-articular viscosupplementation. The exact date of this prior treatment is not clear in the records, but it appears to have been greater than six months prior to this request. There is no documentation that the Supartz is medically reasonable and necessary for the patient. The effectiveness of more than one treatment course with Supartz has not been established. Treatment with more than one course of Supartz is not considered safe and effective or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Supartz.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).

You asked the Plan to pre-approve a shower chair. You say that you have fallen 3 times and want to avoid any
further falls. 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 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 (E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve supply allowance for therapeutic continuous glucose monitor (CGM) (K0553).

You asked the Plan to pre-approve CGM supply allowance. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically reasonable or necessary.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CGM supply allowance. Our reviewer says that the item is not medically necessary. Our physician reviewer found There is no documentation in the records that the enrollee has been performing frequent (four or more times a day) blood glucose testing. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CGM supply allowance have not been met. Specifically, the enrollee does not meet the criteria for a CGM. This means the supply allowance is also denied as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve supply allowance for therapeutic continuous glucose monitor (CGM) (K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation that you have tried and failed prior attempts at treatment.

The Plan must follow Medicare rules. Medicare rules say that dorsal column stimulators are covered if the above criteria have been 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The patient does not have an indication for a spinal cord stimulation trial and also has not seen a surgeon. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required
(D2950 x2).

You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service
is not covered under the enrollee's benefit 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 two
core buildups, including any pins when required (D2950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system, any type (E2300).

You asked the Plan to pre-approve power seat elevation system. You say that the service is medically necessary. The Plan denied your request. The Plan says thitem is not medical in nature.

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 the wheelchair accessory, power seat elevation system, any type (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM receiver (K0554) and supplies and accessories for a CGM (K0553).

You asked the Plan to pre-approve a CGM receiver and CGM supplies and accessories. You say that you do not have time to take out a kit and check your levels and it is better to have something that will warn you if your levels get too low. 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day; nor does the record indicate that you use use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM receiver and CGM supplies and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM receiver (K0554) and supplies and accessories for a CGM (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approved a pneumatic compression device (E0652)and
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).

You asked the Plan to pre-approved a pneumatic compression device and appliance. You say that it is
documented that the enrollee has undergone conservative treatments for her lymphedema with no significant
improvement. A basic pump will be unable to provide satisfactory treatment for her condition. The Plan denied
your request. The Plan says the coverage criteria has not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approved a pneumatic compression device
(E0652)and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).