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

We decided that the Plan does not have to waive the cost share for the medical services provided from January
29, 2020, and March 25, 2020.
You asked the Plan to waive the cost share for the services provided. You say that the cost shares for the
services vary greatly. The Plan denied your request. The Plan says the cost shares were 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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare
Part B prescription drugs 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 cost share for the medical
services provided from January 29, 2020, and March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom oral appliance. 
 
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 a custom oral appliance is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has mild obstructive sleep 
apnea (OSA). The records do not show that she has had a face-to-face visit with a practitioner prior to a sleep 
test to assess for testing. There is no detailed sleep history or upper airway examination. The criteria for the 
oral appliance are not met and 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 custom oral appliance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that an inpatient level of 
care is medically necessary, reasonable, and appropriate. The Plan denied your request. The Plan says the 
requirements for coverage of inpatient psychiatric care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital 
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee was admitted to the acute inpatient psychiatric hospitalization on January 22, 2021, with Severe 
Dementia, Chronic Prescription Benzodiazepine Use and Adjustment Disorder with Mixed Anxiety and 
Depressed Mood. Based upon review the records provided it was not expected this enrollee would improve in a 
reasonable period of time as she did not have dangerousness to self or others and was not showing any 
auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as she did not have dangerousness to self or others. It did not appear that the services were reasonably expected 
to improve the enrollee's condition or for the purpose of diagnosis. The enrollee is noted to be cooperative and 
compliant with treatment while not showing any aggressive behaviors. 
 
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 inpatient psychiatric hospital services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close medical supervision to 
prevent readmission and that a lower level of rehab would reduce his ability to regain maximal function. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for IRF 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 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 seen in the hospital and found to have had a right cerebellar 
stroke.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The 1/27 lab results 
do not indicate the patient's medical management has been completed as there is evidence of electrolyte 
abnormalities and increasing creatinine. The patient's medical status does not require intensive physician or 
nursing supervision in an IRF at this point and still requires acute care management per the 1/27 medical notes. 
The patient?s functional level with documented lethargy and dizziness in therapy does not appear to tolerate or 
require therapy on an intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe subcutaneous cardiac rhythm monitor. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says this facility is not in-network and there are in-network facilities 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-approvethe medical services 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-approvean Ex-N Flex leg exercise machine.You asked the Plan to pre-approvean Ex-N Flex leg exercise machine.You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is 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. 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-approvean Ex-N Flex leg exercise machine
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCarb/Levo Tab 25-100mg.You asked the Plan to pre-approveCarb/Levo Tab 25-100mg. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveCarb/Levo Tab 25-100mg.Benefits for Carb/Levo Tab 25-100mgmay be available under Medicare Part D.Contactthe 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 pre-approvea bridge for teeth #11, 12, 13, and 14.You asked the Plan to pre-approvethe bridge. You say that you are supposed to have tooth #13 extracted. You say that you have pain and the tooth needs to be removed. You also say that you will need a replacement tooth because without it, you will not be able to eat and it will not look right.The Plan denied your request. The Plan says the bridge is 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 bridge when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the bridge. Our reviewer says that the bridge does not meet the criteria for coverage. Our physician reviewer found teeth #4, 5, and 13 are posterior teeth. The Policy provisions state that bridges are not covered if there are missing posterior teeth. Therefore the reviewer found that the criteria for coverage of a bridge has not been met and there is no necessity for the requested procedures.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 bridge have not been met.Therefore, we decided that the Plan does not have to pre-approvea bridge for teeth #11, 12, 13, and 14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea treadmill and stationary bike.You asked the Plan to pre-approveexercise equipment. You say that this equipment is medically necessary because you cannot go to gyms due to the pandemic.The Plan denied your request. The Plan says exercise equipment 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.  This equipment does not serve a purpose that is primarily medical in nature. This equipment 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-approvea treadmill and stationary bike.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran occlusal guard.You asked the Plan to pay forthe occlusal guard. You say that you need a mouth splint because you grind your teeth at night.The Plan denied your request. The Plan says the Plan was not timely with your appeal request, and a decision was not made.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 pay foran occlusal guard.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need to stay in a safe driving range. The 
Plan denied your request. The Plan says there are in-network providers that can provide the care you require. 
 
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 were able to confirm that the Plan has 
contract providers located within reasonable distance and travel time from your home who can provide the 
necessary services. 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 medical services 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-approvetotal electric hospital bed (E0296).You asked the Plan to pre-approvethehospital bed. You say that the hospital bed is necessary.The Plan denied your request. The Plan says the hospital bed is not covered.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  The height adjustment feature is a convenience feature.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-approvetotalelectric hospital bed (E0296)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomprehensive orthodontic treatment of the adult dentition (D8090).You asked the Plan to pre-approvethe dental service. You say that the incorrect CPT code was submitted initially. You say that there is no specific CPT code to describe orthodontic treatment. You say that the service was for the replacement of her teeth after the enrollee sustained a fall.The Plan denied your request. The Plan says the service provided is dental in nature. The Plan also says that comprehensive orthodontic treatment of the adult dentition is not a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecomprehensive orthodontic treatment of the adult dentition (D8090)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because the Prolia is
medically necessary. The Plan denied your request. The Plan says the dispensing plan does not meet Part B
criteria.
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 Prolia.
Benefits for the Prolia 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveJardiance.You asked the Plan to pre-approveJardiance. You say that the medication is necessary.The Plan denied your request. The Plan says your plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed bythe plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveJardiance.Benefits for Jardiancemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of abdomen and 
pelvis to be completed at a tertiary facility. 
 
You asked the Plan to pre-approve the CT scan of abdomen and pelvis to be completed at a tertiary facility. 
You say that you need this CT scan to be performed at a tertiary facility. The Plan denied your request. The 
Plan says there is no reason that this service needs to be performed at a tertiary facility. 
 
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 CT scan of abdomen and pelvis to 
be completed at a tertiary facility. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the service requested can be 
provided by the contracted facility that the Plan has already approved. In this instance, the tertiary care center is 
not necessary as the service can be provided by the contracted facility.  There is no indication for it to be 
performed elsewhere. 
 
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 CT scan of abdomen and pelvis to be completed at a tertiary facility have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) 
scan of abdomen and pelvis to be completed at a tertiary facility.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the records provided support the 
need for inpatient care. The Plan denied your request. The Plan says that inpatient care is not medically 
necessary, as the services needed could be delivered at any 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient hospital care are met in this case. 
Our physician reviewer found the records show that, at the time of inpatient admission, the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department 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 been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON services. You say that in-network specialists are not able to assist you in getting treatment.The Plan denied your request. The Plan says 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 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-approvemedical services 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 pay fora power scooter provided by an out-of-network provider on July 3, 2020.You asked the Plan to pay forthe scooter. You say that this should be paid for.The Plan denied your request. The Plan says prior authorization is required.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out-of-area urgent care,and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could haveprovided 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 fora power scooter provided by an out-of-network provider on July 3, 2020