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

We decided that the Plan does not have to pre-approve Xgeva.

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 a past medical history
of prostate cancer. There is no documentation that the Xgeva is medically reasonable and necessary for him, as
the submitted records do not document confirmation of metastatic disease to bone. The records and Medicare-approved
compendia do not support that Xgeva is safe and effective and reasonable and medically necessary at
this time.

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 Xgeva.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth # 15.
You asked the Plan to pre-approve the dental service. You say that this service should be covered. The Plan denied your request. The Plan says clinical crown lengthening is not listed as 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 clinical crown lengthening (D4249) for tooth # 15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara oscillation system (E1399).
You asked the Plan to pre-approve the Volara oscillation system. You say that you are appealing the denial of
the requested portable oxygen monitor. You need to be on oxygen day and night and cannot be without it. The
Plan denied your request. The Plan says Volara is considered an experimental device as there is not enough
clinical studies for the use of this device in an in-home setting.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Volara oscillation system have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Volara oscillation system (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit.

You asked the Plan to pre-approve a TENS unit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not meet Medicare guidelines to show that this requested device is 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 a TENS unit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided to support that the member is enrolled in an approved clinical study that meets all of the requirements listed in the NCD to support that the request is reasonable and 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 a TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise peddler with electronic display.

You asked the Plan to pre-approve exercise peddler with electronic display. You say that this request is medically necessary. The Plan denied your request. The Plan says Medicare does not cover exercise equipment.

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 exercise peddler with electronic display.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathtub lift.

You asked the Plan to pre-approve bathtub lift. You say that the enrollee needs this due to her condition.The Plan denied your request. The Plan says this item is not primarily medical in nature and is not covered by Medicare.

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 bathtub lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 10, 2020.

You asked the Plan to pay for foot orthotics. 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 pay for foot orthotics provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for alveoloplasty (D7320 x2) provided on December 7, 2020.

You asked the Plan to pay for alveoloplasty. You say that you thought these services would be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of two every calendar year.

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 alveoloplasty have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service. Therefore, we decided that the Plan does not have to pay for alveoloplasty (D7320 x2) provided on December 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 home health OT visits and 4 home health PT visits.

You asked the Plan to pre-approve 14 home health OT visits and 4 home health PT visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 14 home health OT visits and 4 home health PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the skilled therapy services are not required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 14 home health OT visits and 4 home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 home health OT visits and 4 home health PT visits.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reprocess the claim for the CT scan and lab test. We decided that the Plan does not have to waive the cost sharing for the MRI of the brain.

You asked the Plan to reprocess the claims for these services. You say that the 60-day time limit should apply from the time that you got the additional information you needed to request reimbursement. In addition, you believe that only one copayment should apply for the MRIs you received in December since you do not know why one part was billed by a separate provider. The Plan says that you did not submit your request for reimbursement within the 60-day time limit, and the cost sharing was correctly applied to the MRI services.

We decided that the Plan has to reprocess the claim for the CT scan of the chest and lab test.

Medicare rules allow one calendar year from the date of service for claims to be submitted for reimbursement. 

Although the Plan's contract indicates that claims for reimbursement must be submitted within 60 days, the Plan cannot have rules that are more restrictive than Original Medicare. This claim must be considered timely because it was submitted within one calendar year of the date of service. Therefore, we decided that the Plan has to reprocess the claim for the CT scan of the chest and lab test.

We also decided that the Plan does not have to waive the cost sharing for the MRI of the brain.

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 $250 copayment for out of network advanced imaging. 

In this case, although you received the imaging services in the same visit as the MRI of the spine, these are considered different MRI scans. You were correctly asked to pay $250 for the MRI of the entire spine, and $216.54 for the MRI of the brain. 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 cost sharing for the MRI of the brain.

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 to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.

You asked the Plan to pre-approve wig. You say that the enrollee is currently undergoing treatment for breast cancer and hasalopecia due to the drugs.The Plan denied your request. The Plan says this item is not covered by Medicare.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. 

It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 4, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you were never charged a copayment for the same service in the past and 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 $210 copayment for diagnostic radiology services provided at a network hospital facility. 

You have been asked to pay the allowed amount of $98.15, which is less than the $210 copayment for a CT scan. A CT scan 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 copayment for a CT scan provided on February 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on November 25, 2020.

You asked the Plan to waive the copayment for emergency care. You say that you were vomiting and told to go to the emergency room.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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for emergency care. 

Emergency care falls within the emergency care 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 copayment for emergency care provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of continuous positive airway pressure
(CPAP) treatment.
You asked the Plan to pre-approve continuation of CPAP treatment. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for continued
CPAP use.
The Plan must follow Medicare rules. Medicare rules say that continued CPAP treatment is covered when there
is objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. Adherence
to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a
consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
We looked at the file and Medicare rules. Review of the file shows that you do not meet the required adherence
of your CPAP device. Based on this information, we decided that Medicare rules for coverage of continuation
of CPAP treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve
continuation of continuous positive airway pressure (CPAP) treatment.
As stated in the beginning of this letter, the Plan has approved 60 additional days to work on increasing
compliance and tolerance of the mask and then compliance can be re-evaluated after the 60 days to see if you
meet continued use compliance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for vision care provided on November 18, 2020.

You asked the Plan to waive the co-payment for vision care. You say that you should only owe a specialist co-payment and 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for each exam to diagnose and treat diseases and conditions of the eye for vision care.

You have been asked to pay a $30 co-payment for vision care. Vision care falls within the vision care 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 vision care provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic diagnostic imaging provided by an out-of-network provider on February 3, 2021.

You asked the Plan to pay for the ophthalmic diagnostic imaging. You say that that you are in-network with the Plan and shouldn't need a referral. You say that the claim should be processed and paid at the allowed amount. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 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 ophthalmic diagnostic imaging provided by an out-of-network provider on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and the full mouth x-ray (D0210) provided on February 3, 2021.

You asked the Plan to pay for the dental services. You say that you were not informed of the 5 year allowance. You say that had you been, you would have requested your records from your previous provider. You say that you cannot afford the bill that you received. You also say that you feel you were misinformed. The Plan denied your request. The Plan says that 1 comprehensive oral evaluation is covered every 3 years. The Plan says that full mouth x-rays are covered once every 5 years. The Plan also says that the frequency limits for these services have been exceeded.

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 dental services when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. The record shows that you received a comprehensive oral evaluation and full mouth x-ray that were paid for under the prior plan. The current plan has not provided these services. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and the full mouth x-ray (D0210) provided on February 3, 2021.

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 to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide the supply allowance for therapeutic continuous glucose monitor.
You asked the Plan to provide the supply allowance (K0553). You say that the enrollee needs the supply allowance. The Plan denied your request. The Plan says criteria is not met for a therapeutic continuous glucose monitor therefore related supplies are not covered.
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 the enrollee does not use insulin with at least three daily injections, nor requires 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 the supply
allowance (K0553) have not been met. Therefore, we decided that the Plan does not have to provide the supply allowance for therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and electronic connection, transit securement package, and wheel bumpers for a power wheelchair (PWC).

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 covered.

The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness and electronic connection is included in base PWC models. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

We looked at the file and Medicare rules. The requested expandable controller with harness upgrade and electronic connection is not covered because the approved equipment comes with its own power switches. The requested transit securement package and wheel bumpers are not covered because they do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and electronic connection, transit securement package, and wheel bumpers for a power wheelchair (PWC).