Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive
physician or nursing supervision in an IRF. While you may benefit and participate in multiple therapies your
functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because these inserts are necessary for you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic for tooth #14, and retainer crowns for tooth #'s
13 and 15.

You asked the Plan to pre-approve the pontic and retainer crowns. You say that you do not understand why
these services are not covered. The Plan denied your request. The Plan says 3-unit bridges to replace posterior
teeth are not covered. The Plan also says that tooth #14 is a posterior tooth.

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
pontic for tooth #14, and retainer crowns for tooth #'s 13 and 15.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 28, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveendodontic therapy (tooth #6 and #8) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysif a service is not listed in the benefit chart,then it is not covered.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 Plandoes not haveto pre-approveendodontic therapy (tooth #6 and #8) for the enrollee.
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 you need this because you have a high fall
risk. The Plan denied your request. The Plan says this 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. Telephone alert
systems are emergency communications systems and do not serve a diagnostic or therapeutic purpose.
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 waive the charges for the eye exam and refraction testing.

You asked the Plan to waive the charges for the eye exam and refraction testing. You say that you have never
had to pay anything for these services. You feel this was just a routine eye exam. The Plan denied your request.
The Plan says you were seen by an ophthalmologist for a medical eye exam related to your dry eye syndrome.
As such, the $40 copayment applies. In addition, the refraction cannot be covered since it was not done as part
of a routine eye exam.

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 $40
copayment for exams to diagnose/treat diseases or conditions of the eye. The rules also say that eye refraction
testing is never covered by Medicare.

You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the exams to
diagnose/treat diseases or conditions of the eye benefit category. The denial of the refraction is appropriate
because this is not a Medicare-covered service. 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 charges for the eye exam
and refraction testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer.

You asked the Plan to pre-approve the device. You say that you would like reconsideration because clinical evidence supports the use of this device. The Plan denied your request. The Plan says this device 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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus vaccination (90715, 99397, 90471).

You asked the Plan to pay for the vaccination. You say that the service was medically necessary. The Plan denied your request. The Plan says this vaccine is not covered under the Part B benefit unless it is provided as treatment to an injury.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the vaccination. Therefore, we decided that the Plan does not have to pay for a tetanus vaccination (90715, 99397, 90471).

Benefits for the vaccination 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve the massage therapy. You say that you believe therapeutic massage therapy is medically necessary. The Plan denied your request. The Plan says massage therapy is not a covered benefit.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator.

You asked the Plan to pre-approve an Inogen portable oxygen concentrator. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the
requested item.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.

The file shows that you have an oxygen concentrator. Your current oxygen concentrator serves the same
purpose as an Inogen portable oxygen concentrator. In addition, the documentation does not include a
physician order for the requested item. The documentation does not support that you require a replacement
oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve an Inogen portable
oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).

You asked the Plan to pre-approve the insertion of a Vertiflex 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 a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the device. 

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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed tomography, (CT) scan of chest w/ contrast (71260).

You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee doe not meet the criteria as they have already had the three years of CT scans for surveillance purposes.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the Medicare criteria for coverage were not met. Our physician reviewer found the enrollee with has completed 3 years of surveillance CT scans and does not meet the criteria. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed tomography, (CT) scan of chest w/ contrast (71260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration because your doctor prescribed these to you prior to a procedure. The Plan denied your request. The Plan says the specific gradient compression stockings your physician has prescribed are not covered for any reason because they do not meet the definition of a surgical dressing.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve INN coverage for the dental cleanings to be provided by an OON provider.

You asked the Plan to pre-approve INN coverage for the dental cleanings. The Plan denied your request. The Plan says the service will be covered at the OON benefit level for your plan. The Plan also says that this approval is at the OON benefit level because these services are available from an in-network provider and you are choosing to use a provider outside your 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 INN coverage for the dental cleanings to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve gastroenterology visit. You say that this provider is an expert on your condition, and you need to go there for treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.

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 the 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-approve a power seat elevation feature (E2300).

You asked the Plan to pre-approve a power seat elevation feature. You say that you require the power wheelchair. The Plan denied your request. The Plan says that the seat elevator is statutorily non-covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular partial
denture.

You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that
you would like to appeal these services. The Plan denied your request. The Plan says these services are allowed
one time every sixty months. The Plan also says that you had these services less than sixty months ago.

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, dentures are limited to one set every
five years. The record shows that you received a complete maxillary denture and a mandibular partial denture, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does
not have to pre-approve a complete maxillary denture and mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the Plan may authorize referrals to out-of-network providers (OON) in limited situations, including when services meeting the standard of care are not available within the provider network, and when emergent OON care has been provided.

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 physician's services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the acupuncture services. You say that the enrollee cannot travel to where the plan's designated doctor is and greatly benefits from acupuncture. It would be a burden to try to get to that location. The Plan denied your request. The Plan says this provider does not have Medicare credentials to accept payment. Enrollee's must receive medical services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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. This provider does not have Medicare credentials to accept payment for services. 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 the acupuncture services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 6, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided  on June 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on April 9, 2020.You asked the Plan to pay forthe ambulance services. You say that your records show services are paid.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when thereis no transport. The ambulance company did not provide transport services on April 9, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on April 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 20, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated by the medics and confirmed stable.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 20, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on August 20, 2020.