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

We decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crown (D6750).
You asked the Plan to pre-approve the pontic (D6240) and retainer crown (D6750). You say that the original bridge is too heavy for the teeth underneath. You say that the new dentist recommends a bridge. The Plan denied your request. The Plan says the service exceeds the maximum allowed per period.
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, you also have a maximum benefit of one pontic and retainer crown per tooth every 5 plan years. The Plan paid for pontics and retainer crowns provided on September 13, 2017, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crown (D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition services provided to the enrollee on
December 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the submitted documentation did not include sufficient detail to support the service as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is:
HCPCS B4189:
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and
vitamins, including preparation, any strength, 10 to 51 grams of protein - premix
HCPCS B4220:
Parenteral nutrition supply kit; premix, per day
HCPCS B4224:
Parenteral nutrition administration kit, per day
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 the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found there is
no evidence that B4199 x 5, B4220 x 5 and B4224 x 5 were administered to the enrollee on any date.
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 pay for parenteral nutrition services provided to the enrollee on December 17, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 19, 
2019 to January 8, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from December 19, 2019 to January 8, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have a lot of pain in your foot and it's hard 
to walk. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need a power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Surgery
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 be processed at the in network benefit level. 
 
You asked the Plan to pre-approve the OON services being processed at the in network benefit level. You say 
that the records provided support the need for the services in dispute. The Plan denied your request. The Plan 
says the procedure is approved, but the in network benefit exception is not because there are in network 
providers who can supply the service. The Plan says that the enrollee can continue seeing an out of network 
provider, but that the out of network benefits would apply. 
 
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 at the in network rate , only in 
cases involving emergencies, out of area urgent care and care that cannot be provided by in 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 at the in network benefit level. Therefore, we decided that the Plan 
does not have to pre-approve medical services to be provided by an out of network (OON) provider be 
processed at the in network benefit level.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing, and BART 
testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no personal history of breast, ovarian, or pancreatic cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal is being requested solely for screening purposes. There is no evidence of a 
personal history of cancer. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing, and BART testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from March 5, 2020 to March 31, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from March 5, 2020 to March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2), two drugs or 
medicaments dispensed in the office for home use (D9630 x2), comprehensive oral evaluation (D0150), and 
complete series of intraoral x-rays (D0210). 
 
You asked the Plan to pre-approve the gingival irrigations, drugs or medicaments, comprehensive oral 
evaluation, and complete series of intraoral x-rays. You say that you do not agree with the decision the Plan has 
made. The Plan denied your request. The Plan says gingival irrigation and drugs or medicaments are not 
covered benefits. The Plan also says that your comprehensive oral evaluation and complete series of intraoral 
x-rays benefits have been exhausted. 
 
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, gingival irrigation and drugs or 
medicaments dispensed in the office for home use are not among those covered under this benefit. The contract 
also clearly states that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) 
are each limited to one procedure every three plan years. The record shows that you received a comprehensive 
oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on February 5, 2020, and your 
comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been 
exhausted.  
 
 
Therefore, we decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2), two 
drugs or medicaments dispensed in the office for home use (D9630 x2), comprehensive oral evaluation 
(D0150), and complete series of intraoral x-rays (D0210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a continuous glucose monitor.
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. The record shows the enrollee is not on insulin. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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. The Plan denied your request. The Plan says the enrollee does not require physician supervision or a multidisciplinary 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 was admitted for management of a hip fracture. His medical problems are stable. There are no complex nursing or rehabilitation needs. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for physical and occupational therapy, but does not support the need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore, the requested IRF services are 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair elevator. 
 
You asked the Plan to pre-approve a stair elevator. You say that you were recently diagnosed with Parkinson's 
Disease and is having difficulty using stairs. You want to be able to have a chair lift/elevator put in your house. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair elevator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical, occupational, and speech therapy services to 
be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve OON physical, occupational, and speech therapy. You say that the enrollee 
has been receiving services from the requested provider and you are not able to drive her to multiple locations. 
The Plan denied your request. The Plan says these services are 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 
physical, occupational, and speech therapy services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee beginning August 25, 2020.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can be treated in a lower level of care.
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee in this case. This enrollee does not appear to require inpatient mental health treatment beyond the date in question as she is not a danger to herself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It does not appear that active treatment was taking place beyond the date in question. It does not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee beginning August 25, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine (72141). 
 
You asked the Plan to pre-approve the MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found an MRI can provide more information about the 
etiology of the enrollee's symptoms. It also provides a higher degree of anatomical resolution which can help 
lead to a determination if the enrollee's shoulder pain is due to nerve compression. The findings of MRI can 
also help guide any further decisions that may be made with regards to future treatment and/or intervention. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the cervical spine (72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy to be provided by an endodontist. 
 
You asked the Plan to pre-approve the endodontic therapy. You say that you are in extreme pain, and the 
abscess is not going away with antibiotics. The Plan denied your request. The Plan says your contract provides 
no benefit for a root canal, or for services to be performed by an endodontist. 
 
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. The contract also clearly states that dental services must be performed 
by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve endodontic 
therapy to be provided by an endodontist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee. 
 
You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary. The Plan denied your 
request. The Plan says that they did not receive documentation supporting the medical necessity for a step 
therapy exception. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz FX. Our reviewer says that 
Supartz FX is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and 
failed Orthovisc and Monovisc. There is no documentation provided indicating that Orthovisc and Monovisc 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found 
that the enrollee's condition does not meet step therapy criteria for Supartz FX. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX for the enrollee.