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

We decided that the Plan does not have to pre-approve addition to lower extremity identified with code L5629.
You asked the Plan to pre-approve addition to lower extremity. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that additions identified with code L5629 are noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of addition to lower extremity have not been met. Therefore, we decided that the Plan does not have
to pre-approve addition to lower extremity identified with code L5629.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20-10mg NUEDEXTA Capsules.
You asked the Plan to pre-approve the NUEDEXTA. You say that you would like reconsideration because this drug is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this medication falls under Part D coverage, but member has no Part D pharmacy benefit.
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 20-10mg NUEDEXTA Capsules.
Benefits for the NUEDEXTA 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says it is unclear if the enrollee is taking psychotropic medications, whether or not she has benefited from past therapy, and whether or not she has made progress towards reaching treatment goals.
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 treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the enrollee improving or worsening with therapy rendered. There is no documentation showing a clear need for the requested visits. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health treatment for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is being moved to a chair occasionally
so that he doesn't get bedsores. You say that the enrollee does not have any type of walker or crutches in his
room that would indicate he is receiving consistent rehabilitative services. You say that the enrollee may get
pneumonia just lying there with his history of COPD if he is not transferred. The Plan denied your request. The
Plan says the enrollee does not have any acute or new medical conditions. The Plan says that the enrollee has
not had any post-operative complications. The Plan says that the conditions the enrollee has have been wellcontrolled
at the skilled nursing facility (SNF).
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was medically stable with no evidence of a need for supervision by a
physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care.
Functionally, given the enrollee still needs physical therapy and occupational therapy, and is experiencing
shortness of breath with minimal exertion, will not tolerate IRF level of therapies. He also has dementia with
cognitive deficits and may not have the ability to carry over learned skills in physical therapy and occupational
therapy. The enrollee may benefit from further physical therapy and occupational therapy but does not require
an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current
medical stability.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) for teeth number 8 and 9.
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 these services are not a covered benefit under your contractual policy.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) for teeth number 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion spacer device implantation for the enrollee.You asked the Plan to pre-approve the services. You say that it is your professional opinion that this procedure would provide significant clinical and quality of life benefits.The Plan denied your request. The Plan says currently, these devices are still being studies to see if this treatment is reasonable and necessary to be covered by Medicare.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this spacer is experimental, and more research is needed to show 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve Superion spacer device implantation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
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 this service is not a covered benefit under the enrollee's
contractual policy.
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 service is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete
upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implants (D6010 x 2), bone grafts (D6104 x 2), and guided tissue regeneration (D4266 x 2).
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 these services are not a covered benefit under your contractual policy.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implants (D6010 x 2), bone grafts (D6104 x 2), and guided tissue regeneration (D4266 x 2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Pelvis (72192).
You asked the Plan to pre-approve the CT scan. You say that the CT scan 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 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
CT scan of the Pelvis is not medically necessary. Our physician reviewer found the documentation does not
outline any concerning complaints, physical exam or study findings to support CT evaluation of pelvis.
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) of the Pelvis (72192).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for sphere, bifocal, Plano to plus or minus 4.00d, per lens (V2200) provided on February 26, 2020 from an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that your coverage includes a pair of glasses and there is nothing in the statement of benefits that says you could not purchase the glasses. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The claim was
not denied on  involvement, but because the services are not covered. You have no other vision benefit other than receiving glasses after cataract surgery. The plan reviewed your 2019 claim history and did not find any cataract procedures in which this benefit would apply. Therefore, we decided that the Plan does not have to pay for sphere, bifocal, Plano to plus or minus 4.00d, per lens (V2200) provided on February 26, 2020 from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3.
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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 10, 2019 to July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical boot provided on January 17, 2020.
You asked the Plan to pay for the surgical boot (L3260). You say that you could not walk on the cast without
the surgical boot. 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 pay for the surgical boot provided on January
17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you want to appeal the Plan's denial of the requested shower chair because it is not a hygiene related item for you. You say that you have medical conditions that make it very difficult for you to stand for any length of time to take a shower. You stated that you previously were given a shower chair by your physician, however it has developed a crack and could collapse. You say that you need the requested shower chair so that you can sit down to take a shower. You asked the plan to reconsider their denial of the shower chair because you say that you are not requesting it for hygiene reasons. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower chair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from January 18, 2020 to January 19, 2020.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for any deductible, copayment, or coinsurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 an $80 copayment for emergency services at an in-network emergency room. You have been asked to pay an $80 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided from January 18, 2020 to January 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair attendant control feature.
You asked the Plan to pre-approve the power wheelchair attendant control feature. You say that you need the attendant control feature. The Plan denied your request. The Plan says there is no documentation provided to explain why someone other than you would need to control the wheelchair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The Wheeled Mobility and Seating Evaluation shows you are able to operate a power wheelchair safely. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair attendant control feature.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance transport provided on September 5, 2019.
You asked the Plan to waive the deductible for the ambulance transport. You say that you should not be responsible for this amount. The Plan denied your request. The Plan says that this was applied to your deductible correctly.
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 covered medical services. The item or service you asked the Plan to waive the deductible for falls within the benefit category of covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on September 5, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance transport provided on September 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (J7321).
You asked the Plan to pre-approve Supartz. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirements have not been 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 Supartz. Our reviewer says that the
criteria for coverage of Supartz has not been met. Our physician reviewer found the Plan requires a trial of
Orthovisc and Monovisc before they will approve the requested drug. The documentation does not support that
the enrollee has tried Orthovisc and Monovisc, or that these drugs would likely be less effective or have
adverse effects for the enrollee 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 Supartz have not been met. Therefore, we decided that the Plan does not have to
pre-approve Supartz (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powder free, Nitrile sterile gloves.
You asked the Plan to pre-approve the sterile gloves. You say that it is necessary for you to use gloves in your
daily bowel care and catheterizations. The Plan denied your request. The Plan says this item is not covered
under 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.
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 powder free, Nitrile sterile gloves.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a cystourethroscopy with the insertion of
an implant (81002, 52442, 52441) provided by an out-of-network (OON) provider on February 18, 2020.
You asked the Plan to waive the coinsurance for an OON cystourethroscopy. You say that you cannot afford
this charge. The Plan denied your request. The Plan says this processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50%
coinsurance for out-of-network outpatient surgery services.
You have been asked to pay a $2,983.45 coinsurance for an OON cystourethroscopy ($5,966.92 allowed
amount x 50% = $2,983.46). An OON cystourethroscopy falls within the out-of-network outpatient surgery
services benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a cystourethroscopy with
the insertion of an implant (81002, 52442, 52441) provided by an out-of-network (OON) provider on February
18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.
You asked the Plan to pre-approve Xiidra eye drops. You say that this is the only medication that works for the enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Xiidra eye drops.
Benefits for Xiidra eye drops may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.