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

We decided that the Plan does not have to pre-approve Ventolin HFA for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Ventolin HFA for the enrollee.
Benefits for this drug 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.You asked the Plan to pre-approvehome health aide services. You say that it is difficult for the enrollee to do activities around the house.The Plan denied your request. The Plan says the enrollee is not receiving skilled services at home.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our physician reviewer found that the documentation does not reveal the enrollee is getting skilled nursing or skilled physical therapy. The requested services of cooking and companionship are not reasonable and necessary to the treatment of the enrollee's illness or injury. The request for home health aide services is not reasonable and necessary to the treatment of the enrollee by the skilled professional staff.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approvehome health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057 x 3) and the abutment supported crown (D6058 x 3) provided on October 16, 2019. You also asked the Plan to reimburse you for the $100 deductible.
You asked the Plan to pay for the dental services. You say that you submitted a preauthorization prior to receiving the services. You also say that you have been charged for your deductible twice. The Plan denied your request. The Plan says the custom fabricated abutment and the abutment supported crown are not listed as covered services. The Plan also says that the $100 deductible was only applied to the surgical extraction that you received on February 27, 2019.
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 dental services that you received on October 16, 2019 are not among those covered under this benefit. Additionally, there was no deductible applied on March 6, 2019. The documentation dated March 6, 2019 is an explanation of how payments might be applied to the requested services. This documentation specifically says "actual dates of service may alter the deductible application and benefits payable." Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057 x 3) and the abutment supported crown (D6058 x 3) provided on October 16, 2019. We also decided that the Plan does not have to reimburse you for the $100 deductible.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Austedo for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this to treat tardive dyskinesia. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Austedo for the enrollee.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6532.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are necessary to reduce swelling in your feet, where there is pain. The Plan denied your request. The Plan says you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6532.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 4, 2019 to July 5, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that you feel that due to your injury and not being mobile and no in-network hospital available these charges should not have been denied.The Plan denied your request. The Plan says an inpatient admission was not medically necessary as care could have been given in the hospital at an observation level of care.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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 pay forthe acute inpatient hospital care provided July 4, 2019 to July 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), prophylaxis (D1110), and the complete series of periapical x-rays (D0210) provided from November 21, 2019 to November 22, 2019.You asked the Plan to pay forthe dental services. You say that you were never advised that your coverage did not include basic dental coverage benefits including preventive care, exam, cleaning and fillings as most dental plans do.The Plan denied your request. The Plan says the oral exam, prophylaxis, and complete series of x-rays are not listed as covered services.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 preventive dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), prophylaxis (D1110), and the complete series of periapical x-rays (D0210) provided from November 21, 2019 to November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 14, 2019 to October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for home health visit. You say that this service is covered by Medicare and was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 has network providers available who can provide 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 September 14, 2019 to October 17, 2019 by an out of network (OON) provider.
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. You say that the enrollee needs more extensive care. The Plan
denied your request. The Plan says the enrollee does not need a rehab physician 3 times a week, or an intensive
team for care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 IRF care. Our physician reviewer found
that the enrollee is ambulating at minimal assist using a hemi walker. He is moderately independent for bed
mobility, minimal assist for bed to chair transfers, supervision for hygiene, and contact guard assist for upper
body bathing and dressing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
medical status does not require intensive IRF physician or nursing supervision. He may benefit and participate
from physical and occupational therapy, however the documentation does not support that this enrollee requires
intensive rehabilitation therapy 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 October 7, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat for the enrollee.
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 self-administered drugs are not covered.
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 Febuxostat for the enrollee.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and shower chair repairs.
You asked the Plan to pre-approve a shower chair and shower chair repairs. You say that you need your shower
chair repaired but it was denied because you are not at risk. You say that your shower chair needs the wheels
replaced. The Plan denied your request. The Plan says this item is not a covered benefit.
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 and shower chair repairs.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) to be provided by a
pharmacy.
You asked the Plan to pre-approve Botox. You say that you feel this should be approved. The Plan denied your
request. The Plan says the denial of authorization for this drug is correct, because this drug will be supplied by
a pharmacy and is not covered by Medicare Part B under this circumstance. The Plan also says that this drug
has been approved under the enrollee's Medicare Part D benefits.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve onabotulinumtoxina (Botox) to be provided by a pharmacy.
Benefits for Botox 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis
(D1110) provided on December 6, 2019.
You asked the Plan to pay for the dental services. You say that you needed to get your teeth cleaned before
your open heart surgery. You also say that you were advised by your dental insurance that the claim should be
run as medical. The Plan denied your request. The Plan says the oral exam and prophylaxis are dental in nature.
The Plan also says that routine dental care is not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation
(D0120) and the prophylaxis (D1110) provided on December 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve injection for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is not enough medical evidence for this type of injection.
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 requested services. Our physician reviewer found that the enrollee has chronic knee pain due to osteoarthritis. She had a prior radiofrequency ablation of the genicular nerves and had one year of pain relief. This is an experimental/investigational procedure, which is the subject of ongoing clinical trials. Therefore, the requested procedure is deemed not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown with high gold content (D2750) and a ready-made post for filling for a crown (D2954) for tooth # 25.
You asked the Plan to pre-approve the dental services. You say that the records provided are incorrect. You say that the records indicate that the enrollee's tooth was previously extracted. You say that the previous dentist billed a tooth extraction, but the tooth is present in the enrollee's mouth and needs the requested treatment. The Plan denied your request. The Plan says the crown and prefabricated post and core in addition to a crown 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 the dental services 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the documentation provided does not show significant breakdown of the coronal structure of the tooth. The reviewer found that the access opening for the root canal would not weaken the tooth to a great degree and restoration with a filling would restore the tooth to normal function at this time. Therefore, the crown and the post and core in addition to a crown are not medically reasonable and necessary.
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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown with high gold content (D2750) and a ready-made post for filling for a crown (D2954) for tooth # 25.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services
provided to the enrollee from September 9, 2019 to October 4, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that The Plan denied your request.
The Plan says that the copayment is part of the member's contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $160 copayment for each day for days 21 through 44 in a network skilled nursing facility.
The enrollee has been asked to pay a $800 copayment for the SNF services. The SNF services fall within the
days 21 through 44 in a network skilled nursing facility benefit category. This means that the enrollee has been
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for the skilled nursing facility (SNF) services provided to the enrollee from
September 9, 2019 to October 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on August 17, 2019.
You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan says that you are contractually obligated to pay the appropriate copay and/or coinsurance charges for services rendered.
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 $290 copay for Medicare-covered ambulance benefits. You have been asked to pay less than a $290 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance benefits benefit category. This means that you have been asked to pay less than 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 copay for the ambulance transport provided on August 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 14, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment on November 13, 2017 This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 14, 2019.