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

We decided that the Plan does not have to pre-approve a Superion spacer.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The
requested Superion spacer is considered experimental in nature, as more research is needed to support efficacy.
The services are therefore not reasonable 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 a Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature and enhanced color
display for the enrollee.
You asked the Plan to pre-approve a power seat elevation feature and enhanced color display. The Plan denied
your request. The Plan says that these items are not primarily 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 items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation feature and enhanced color display
for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during the knee arthroscopy services provided on December 3, 2019.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 29876. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services during the knee arthroscopy services provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert System.You asked the Plan to pre-approve a Life Alert System. You say that because of health conditions it is medically necessary for the enrollee to have a Life Alert System.The Plan denied your request. The Plan says telephone alert systems are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. A life alert system is an emergency communications system whichdoes not serve a diagnostic or therapeutic purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Life Alert System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and lab work provided on January 24, 2020 by an out of network (OON) provider.You asked the Plan to pay for an office visit and lab work. You say that you were told by the office after your visit that they are outside your network.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services could have been provided in-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 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 office visit and lab work provided on January 24, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.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 item is not covered.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide sensors for use with an interstitial continuous glucose
monitor.
You asked the Plan to provide disposable sensors (A9276). You say that the enrollee needs sensors for the
monitor being used. The Plan denied your request. The Plan says the enrollee is not utilizing a therapeutic
CGM.
The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with
a covered therapeutic continuous glucose monitor.
We find that CPT code A9276 is not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of sensors for an interstitial continuous glucose monitoring system have not been
met. Therefore, we decided that the Plan does not have to provide sensors for an interstitial continuous glucose
monitoring system. Therefore, we decided that the Plan does not have to provide sensors for use with an
interstitial continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis for the enrollee.
You asked the Plan to pre-approve a knee orthosis. The Plan denied your request. The Plan says that there is no
objective evidence of instability.
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 knee orthosis. Our reviewer says that
a knee orthosis is not considered medically reasonable and necessary in this case. There is no mention of knee
swelling, or joint/ligament dysfunction or joint instability. Our physician reviewer found that the enrollee's
condition does not meet Medicare criteria for a knee orthosis.
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 knee orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories (E1007, E2300, E2361, E0955, E1028, E2377, E2313, E2311, E0995, E2603, E2323).You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that you need this device because your current scooter is too big for your apartment.The Plan denied your request. The Plan says you do not meet the criteria for coverage of this device.The Plan must follow Medicare rules. Medicare rules say that a group 3 power wheelchair is covered only if the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. We looked at the file and Medicare rules. The medical records do not show that your mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea group 3 power wheelchair (K0861) and accessories (E1007, E2300, E2361, E0955, E1028, E2377, E2313, E2311, E0995, E2603, E2323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult diapers and other over the counter items.You asked the Plan to pre-approve the items. You say that you cannot afford these items.The Plan denied your request. The Plan says this is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve adult diapers and other over the counter items.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869). You asked the Plan to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental. 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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show that it is safe and effective. 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 insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says prior approval was not obtained for non-emergent services rendered in the service area.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 9, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you have a hard time testing your
glucose on your own. The Plan denied your request. The Plan says the criteria for coverage of a CGM have not
been met.
The Plan must follow Medicare rules. Medicare rules say that CGM devices are covered if you are insulintreated
with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous
insulin infusion (CSII) pump.
We looked at the file and Medicare rules. The submitted medical records do not show that you are insulintreated
with three or more daily injections of insulin or a Medicare-covered CSII pump. Based on this
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor
(CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anterior tooth endodontic therapy for the enrollee.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 anterior tooth endodontic therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flexible outer surface covering system (L5962) for a prosthesis.You asked the Plan to pre-approve the cover system. You say that the flexible outer covering is medically necessary.The Plan denied your request. The Plan says coverage criteria is not met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the cover system. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found the documentation does not reveal that the patient has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of that which is afforded by the already approved cover.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 cover system have not been met.Therefore, we decided that the Plan does not have to pre-approve a flexible outer surface covering system (L5962) for a prosthesis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you need pilates, not just regular physical therapy. The Plan denied your request. The Plan says these services can be provided in-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 physical therapy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint.
You asked the Plan to pre-approve a knee orthosis (L1845). You say that it is painful to walk and your doctor said a brace would help to straighten your knee. The Plan denied your request. The Plan says you have not had a recent knee injury, surgery or exam showing knee joint instability.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis (L1845) have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four semi-precision attachment abutments.
You asked the Plan to pre-approve the four semi-precision attachment abutments. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's 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 four semi-precision attachment abutments.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and shoulder x-ray provided
on December 5, 2019.
You asked the Plan to waive the copayment for the office visit and shoulder x-ray. You say that you think this
should be a wellness visit. You say that you should be refunded. The Plan denied your request. The Plan says
the copayments 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 $25
copayment for each primary care provider visit for Medicare covered benefits and a $20 copayment for
Medicare covered x-rays.
You have been asked to pay a $25 copayment for the office visit and a $20 copayment for the shoulder x-ray.
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The shoulder x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies"
benefit category.
The records show that you were treated for shoulder pain and impacted ear wax during the office visit. 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 the office visit and shoulder x-ray provided on December 5,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments to be provided by an out of network (OON) provider. You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that medically necessary care is available in 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 Group 3 power wheelchair and attachments to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and ECG to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit and ECG. You say that you are more comfortable with this doctor because he knows all your history and heart conditions. The Plan denied your request. The Plan says the member has not been established with this provider for over 12 months. The Plan says this does not meet the criteria for continuity of care. The Plan says that there are in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 an office visit and ECG to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve face masks and gloves.
You asked the Plan to pre-approve face masks and gloves. The Plan denied your request. The Plan says that this is not covered.
The Plan covers all items that Medicare covers. Medicare rules state that face masks are not covered because they are nonreusable disposable items. While face masks and gloves may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve face masks and gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back up battery for a continuous positive airway
pressure (CPAP) device.
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 item is not covered.
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. Therefore, we
decided that the Plan does not have to pre-approve a back up battery for a continuous positive airway pressure
(CPAP) device.