Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that your mother is diabetic but is not insulin-treated because her doctor wants her to work on her diet before receiving pills or insulin. You say that the enrollee was sent to a diabetic educator where she received a glucose scanner, which has helped her tremendously. The Plan denied your request. The Plan says the guidelines for coverage 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 have a diagnosis of diabetes mellitus. Rather, the records provided show a diagnosis of pre-diabetes, hyperlipidemia, and hypertension. The documentation does not indicate that the enrollee is insulin-treated with three or more daily injections of insulin. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth physician services.
You asked the Plan to waive the copayment for these services. You say that the copayment should be waived. The Plan denied your request. The Plan says the copayment cannot be waived.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for each covered visit or consultation in an outpatient location with a specialist.
The services at issue are telehealth services with a specialist. If the enrollee chooses to receive these services, they will be asked to pay a $45 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with a specialist. benefit category. The contract with the Plan states that the copayment for telehealth services is the same as for outpatient office services with a specialist. This means that the enrollee will be asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for telehealth physician services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 months of continued rental of a portable ventilator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the 3-month continued rental of a portable ventilator. You say that you would like reconsideration because the member requires this unit in order to prevent further hospitalizations and continue to breathe. The Plan denied your request. The Plan says the member can receive this equipment 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 3 months of continued rental of a portable ventilator 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 commercial queen sized adjustable bed.
You asked the Plan to pre-approve the commercial queen sized adjustable bed. You say that you would like reconsideration because your doctor prescribed this bed to help your muscle conditions. The Plan denied your request. The Plan says this bed does not meet Medicare's definition of Durable Medical Equipment.
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-approve commercial queen sized adjustable bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Botox. Our reviewer says that Botox is not medically reasonable and necessary in this case. Our physician reviewer found that this is 70-year-old woman has chronic pain in the right anterior/lateral chest wall. She has tried and failed medication therapy, topical medication, TENS and bracing. She had pain relief from Botox injections with improved function. This is an experimental/investigational use of Botox. Therefore, the request is considered 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says this request exceeds the benefit limit.
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 10 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 requested trips will exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant removal (D6100) and two removals of torus mandibularis (D7473 x2).
You asked the Plan to pre-approve the implant removal and removals of torus mandibularis. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits.
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 an implant removal (D6100) and two removals of torus mandibularis (D7473 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services.
You asked the Plan to pre-approve the dental services. You say that these services are necessary because most of your teeth were removed and you require implants. The Plan denied your request. The Plan says these services are not covered by your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound provided by a participating provider on October 28, 2020.
You asked the Plan to waive the deductible for an ultrasound. You say that you thought you would only owe $160. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for outpatient diagnostic tests. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on October 28, 2020. The total amount you are being asked to pay is $230.15. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound provided by a participating provider on October 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional 21 miles (A0170).
You asked the Plan to pre-approve the additional mileage. You say that the hospital is 67 miles away and travel is limited to 50 miles. This trip is for surgery. You are asking for the denial to be reversed so you can have your surgery. The Plan denied your request. The Plan says this request exceeds the benefit limit maximum of 50 miles for each one-way trip.
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. Routine transportation coverage includes 45 one-way transportation per calendar year. Each one-way trip must not exceed 50 miles. You are asking for an additional 21 miles to total 71 miles. This exceeds the maximum allowed. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 21 miles (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
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 high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint radiofrequency ablation.

You asked the Plan to pre-approve facet joint radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is covered for certain indications.

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 facet joint radiofrequency ablation. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has a history of axial low back pain. The enrollee had a spinal cord stimulator placed but it no longer effective. A computerized tomography (CT) scan showed multi-level facet Arthropathy. The enrollee has had radiofrequency ablation of bilateral medical branch blocks in 2016 and 2018 with lasting effect. Radiofrequency ablation lesioning typically lasts six months to two years. The enrollee meets criteria for a repeat radiofrequency ablation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint radiofrequency ablation have been met. Therefore, we decided that the Plan has to pre-approve facet joint radiofrequency ablation.

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 Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee would benefit from Prolia injections. The Plan denied your request. The Plan says there is no indication that the enrollee has had an osteoporosis-related fracture. The Plan also says that the enrollee has not tried and failed Zoledronic acid.
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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). Our reviewer found that there is no documentation provided indicating that the the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also found that the enrollee does not have a history of osteoporotic fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gum surgery procedure (D4266) and a bone replacement graft (D7953).
You asked the Plan to pre-approve the dental procedures. You say that these are necessary procedures. The Plan denied your request. The Plan says neither of these services are covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a gum surgery procedure (D4266) and a bone replacement graft (D7953).
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 services are 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services, but you do not require an intensive inpatient rehabilitation therapy program. There is no documentation that you require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Continue care in the long-term acute care hospital or at the skilled nursing facility level appears to be appropriate in this case.

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-approve a pulse generator and electrodes (L8687, L8680) for a nerve stimulator.
You asked the Plan to pre-approve the pulse generator and electrodes. You say that since the nerve stimulator was approved, the electrodes and generator are required also. The Plan denied your request. The Plan says the codes at issue are not listed as covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare maintains a spreadsheet of covered Durable Medical Equipment, prosthetics, orthotics, and supplies CPT/HCPCS codes. We looked at the file and Medicare rules. The codes requested (L8687, L8680) are no longer listed as covered by Medicare. Payment for the electrodes and generator is included in payment for the stimulator (63650) which has already been approved. Based on this information, we decided that Medicare rules for coverage of the pulse generator and electrodes have not been met. Therefore, we decided that the Plan does not have to pre-approve a pulse generator and electrodes (L8687, L8680) for a nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopaedic services provided on December 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for orthopaedic services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for orthopaedic services provided on December 14, 2020 by an out of network (OON) provider.