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

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and endodontic therapy (D3330).
You asked the Plan to pre-approve the core buildup and endodontic therapy. You say that you do not understand why the Plan would approve a crown for a tooth that needs a root canal. You also say that you thought Medicare paid for root canals and crowns. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and endodontic therapy (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decidedthat the Plan does not have to pay forpin retention, per tooth, in addition to restoration, tooth 31 (D2951) provided January 23, 2020.You asked the Plan to pay forthe dental services. You say that you had this work done as an alternative to a crown which is more expensive. You have been going to this provider for years and it would be very good if he was in your network.The Plan denied your request. The Plan says this service is not covered under the plan benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed under the description of benefits are not covered by the plan.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 pay forpin retention, per tooth, in addition to restoration, tooth 31 (D2951) provided January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2).
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's health 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 gingival irrigations (D4921 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says there is no Medicare benefit for a non-therapeutic continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file, and Medicare rules. The requested items are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says the service is available by a provider in the network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76642) and mammogram (77065) provided on December 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for an OON ultrasound and mammogram. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 an ultrasound (76642) and mammogram (77065) provided on December 24, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the same test or a test like it was done recently on March 2, 2020.
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found a review of the documentation and Local Coverage Determination (LCD): Transthoracic Echocardiography (TTE) (L34338) - Effective September 26, 2019 indicates that the requested test is not medically reasonable or necessary. It is noted that the enrollee had a comprehensive pre-transplant cardiac evaluation on March 2, 2020 which included an echocardiogram and an SPECT stress test. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled services in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our physician reviewer found that you were treated in an acute hospital for dystonia that was felt to be related to Seroquel. You were evaluated by neurology and psychiatry, and the Seroquel was stopped. You have gait instability and speech difficulty, and have received treatment with physical therapy, occupational therapy and speech therapy. The provided medical records do not indicate a need for skilled nursing or therapy services on a daily basis. You do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gammagard Liquid.
You asked the Plan to pre-approve Gammagard. The Plan denied your request. The Plan says there is not enough support for use in the treatment of acquired hypogammaglobulinemia caused by chronic lymphocytic leukemia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gammagard. Our physician reviewer found that the requested use of Gammagard is not FDA-approved for the enrollee's diagnosis. The enrollee does not have hypogammaglobulinemia, or recurrent sinopulmonary infections. His IgG is less than 500. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested Gammagard is not medically 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 Gammagard have not been met. Therefore, we decided that the Plan does not have to pre-approve Gammagard Liquid.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 26, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift chair provided on November 1, 2019 by an out of network provider.You asked the Plan to reimburse you for the seat lift mechanism. You say that you did not realize the Plan would cover your lift chair.The Plan denied your request. The Plan says you did not use 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 reimburse you 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to reimburse you for this item.Therefore, we decided that the Plan does not have to reimburse you for the seat lift chair provided on November 1, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be given more safely at a skilled nursing facility.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. The enrollee may benefit from further PT and OT, but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for progressive lens per lens (V2781) provided on August 14, 2019.
You asked the Plan to pay for the progressive lens. You say that you were guaranteed you would be reimbursed by the Plan. The Plan denied your request. The Plan says that the provider is not part of the network.
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 vision care benefit is not a Medicare benefit. It is a supplemental benefit offered by the plan that has there is a $150 maximum benefit amount for contact lenses, eyeglass frames and eyeglass (unlimited per year). This means that the generic lock-in language in Chapter 3 is not sufficient. The limitation on a plan provider must be specifically listed for the vision care benefit. It is not, neither in the hearing aid section of the benefits chart (Chapter 4) nor in the exclusions list at the end of the benefit chart. The Plan has to pay the $150 maximum benefit for the eyeglasses. Therefore, we decided that the Plan has to pay for progressive lens per lens (V2781) provided on August 14, 2019.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee.
You asked the Plan to pay for non-emergent ambulance services. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. She could have been safely transported by stretcher van. The documentation does not support that the ambulance transport was medically reasonable and necessary for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance for the enrollee.You asked the Plan to pre-approve an oral appliance. You say that this oral appliance is medically necessary.The Plan denied your request. The Plan says medical necessity has not been established.The Plan must follow Medicare rules.Medicare has specific coverage criteria for an oral appliance. 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 an oral appliance. Our physician reviewer found the enrollee has a diagnosis of Obstructive sleep apnea. Polysomnography was performed on December 3, 2017. The enrollee qualified for a diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome. An apnea-hypopnea index of 18.5 which worsened to 44.7 during REM sleep was reported. However, the medical records do not contain documentation of a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the enrollee for obstructive sleep apnea testing.Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oral appliance have not been met.Therefore, we decided that the Plan does not have to pre-approve an oral appliance for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. You say that the requested lab has a 4-hour turnaround time.The Plan denied your request. The Plan says there are in-network providers that can offer the requested services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approve lab services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve Tecentriq. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Tecentriq. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee recurrent, progressive high grade neuroendocrine cancer of the gall bladder and to be given in combination with Carboplatin and Etoposide. The pathology reported in the office notes do not indicate the high grade neuroendocrine cancer was of small cell type. If it were small cell type, the indication for use of Tecentriq in small cell lung cancer is as first line treatment. The enrollee has been previously treated for recurrent, metastatic cancer so the requested use is not first line treatment. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on December 13, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the bloodwork should be fully covered by the Plan. The Plan denied your request. The Plan says the copayment applied correctly.
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 $70 copayment for lab services at an in-network outpatient hospital. You have been asked to pay $21.67, which is less than the standard $70 copayment for laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were billed by the hospital. 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 laboratory services provided on December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onglyza.
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 Onglyza.
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.