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

We decided that the Plan does not have to provide additional payment for the surgical placement of implant
body: endosteal implant (D6010) and bone graft at time of implant placement (D6104) provided March 8,
2021.

You asked the Plan to provide additional payment for the endosteal implant and bone graft. You say that the
service was approved, and you do not understand why the cost is so high. The Plan denied your request. The
Plan says the copayment for the endosteal implant has been applied correctly and the bone graft is not a
covered service.

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.

We reviewed the file and Medicare rules. You have been asked to pay a $2,300 copayment for each endosteal
implant as outlined in the Plan's third-party dental vendor's Schedule of Benefits. Therefore, the Plan does not
have to waive the copayment for the surgical placement of implant body: endosteal implants (D6010) provided
March 8, 2021. Though the Plan offers a dental benefit in excess of Medicare coverage, the bone graft is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone
graft at time of implant placement (D6104) provided March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoe inserts.

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 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 custom shoe inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554).

You asked the Plan to pay for the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine.

You asked the Plan to pre-approve Prochlorperazine. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prochlorperazine have not been met. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.

You asked the Plan to provide additional transportation. You say that you need more transportation. The Plan denied your request. The Plan says this benefit covers a maximum of 60 trips per calendar year. Trips in excess of the 60 provided by the benefit are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the additional transportation requested exceeds what is covered by the Plan's routine transportation benefit. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network
(OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
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 services. Therefore, we decided that the Plan does not have to pre-approve office
visits to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the Part B step therapy criteria is not met.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed Retacrit. There is no indication that Retacrit would likely be less effective and/or likely have adverse effects for the enrollee. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
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 would like the Plan to reconsider their denial. 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 Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve a Freestyle Libre. You say that the enrollee would benefit from the
requested item. The Plan denied your request. The Plan says rules for a continuous glucose monitor have not
been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre continuous glucose monitor.
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 these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.
We looked at the file and Medicare rules. The records show that the enrollee is not treated with three or more insulin injections per day. 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 Freestyle Libre continuous glucose monitor (CGM).
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 these services. You say that you need the device to monitor your inslin. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.

We looked at the file and Medicare rules. The records show that you do not take three or more daily injections of insulin. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core build-up (D2950) for teeth #8 and #9.

You asked the Plan to pre-approve the core build-up. You say that the core build-up is medically necessary. The Plan denied your request. The Plan says this is not a covered service.

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 build-up (D2950) for teeth #8 and #9.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the brain stem for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary, as there has been a decline in cognitive ability. The Plan denied your request. The Plan says that this request cannot be approved.

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 requested MRI is medically reasonable and necessary. Our physician reviewer found while there is no quantification of cognitive decline, such as an MMSE test, the fact that the enrollee has a primary bladder tumor and bone metastasis presents a concern for multi-organ metastatic disease. This concern together with the perception of definite cognitive decline makes the request for MRI of the brain reasonable to evaluate for organic causes of his cognitive decline including cerebrovascular accident, metastatic disease and atrophy. The best imaging tool for such evaluation is MRI of the brain. 

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 MRI of the brain stem for the enrollee.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga 10mg tablet for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.

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 Farxiga 10mg tablet for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of the lower extremities (93970, 93971)
and an office visit (99203) to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
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 services. Therefore, we decided that the Plan does not have to pre-approve a duplex
scan of the lower extremities (93970, 93971) and an office visit (99203) to be rendered by the out-of-network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new CPAP machine.

You asked the Plan to pre-approve the machine. You say that the current machine is nearing five years old, and the enrollee wants a smaller machine with wireless capabilities. The Plan denied your request. The Plan says the beneficiary must have had the durable medical equipment for five years before replacement.

The Plan must follow Medicare rules. Medicare rules say that the typical reasonable useful lifetime for durable medical equipment is five years. 

The current CPAP was approved on July 24, 2017. That is less than five years ago. It appears that the new device is being requested to be smaller and have wireless capabilities. This is a request that is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of the machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a new CPAP machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested item.

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 item at issue in this appeal.

We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy services (63047, 63048) to be provided in an inpatient hospital setting

You asked the Plan to pre-approve acute inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says they have agreed to provide the requested services in an outpatient setting; however, the request for inpatient care is not medically necessary and remains denied.

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 services. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this procedure. The planned procedure listed under codes 63047 and 63048 are not listed on the Centers for Medicare and Medicaid Services (CMS) inpatient only list. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation that this enrollee will require a greater than two midnight stay. The record does not show that at the time of the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The items/services at issue are not medically necessary in this case. The services requested can be safely provided in an outpatient observation level of care. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy services (63047, 63048) to be provided in an inpatient hospital setting
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home oxygen concentrator.

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 you do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 

We looked at this the file and Medicare rules. The records show that your oxygen saturation is not lower than 91% at rest. 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 home oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).

You asked the Plan to pre-approve foot orthotics. You say that the shoe inserts are medically necessary. 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 the requested shoe inserts are not part of a brace and are not a type that is used for the treatment of diabetic food disease. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of these orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a keratotomy procedure.

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 covered.

The Plan must follow Medicare rules. Medicare rules say that a keratotomy is not covered. 

We looked at the file and Medicare rules. The requested procedure is a keratotomy. This procedure is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a keratotomy procedure.