Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because this is a continuation of care for the member's delicate condition. The Plan denied your request. The Plan says there are in-network providers available who may safely monitor the member's condition.

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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia for a dental procedure.

You asked the Plan to pre-approve general anesthesia. You say that you can't take the pain and do not have the money to pay for the anesthesia. The Plan denied your request. The Plan says the service is not a covered 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 general anesthesia for a dental procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #5.

You asked the Plan to pre-approve endodontic therapy. You say that the patient presented with severe tooth pain on tooth number 5 due to extensive decay compromising the tooth structure and exposing nerves. The Plan denied your request. The Plan says the service is not a covered 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 endodontic therapy for tooth #5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group two very heavy-duty power operated vehicle.

You asked the Plan to pre-approve a group two very heavy-duty power operated vehicle. You say that you are a fall risk and feel you need this power wheelchair. The Plan denied your request. The Plan says you do not meet criteria for the requested items.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. A very heavy-duty power operated vehicle is covered for an enrollee weighing 428 - 600 pounds.

The file shows that you weigh less than 428 pounds. This means that Medicare rules for coverage of the requested very heavy duty PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group two very heavy-duty power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).

You asked the Plan to pre-approve periodontal scaling and root planing. You say that the service is necessary to stop your gums bleeding. The Plan denied your request. The Plan says the service will exceed the maximum allowable per period.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal scaling and root planing once per quadrant every two plan years. 

We looked the file and Medicare rules. The Plan provided documentation showing that this service was previously covered on February 14, 2020. Based on this information, we determined that the Plan's frequency limits for periodontal scaling and root planing would be exceeded. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crowns (D2750) and prefabricated posts and cores (D2954) for teeth #2 and #14.

You asked the Plan to pre-approve the crowns and posts and cores. You say that you need crowns in order to save these teeth. You say your health is otherwise in good condition, and you do not have the funds to pay for this treatment. The Plan denied your request. The Plan says that because you are missing more than 6 top teeth, it is not reasonable or appropriate to provide services to restore and save the teeth in question. Your dentist did not provide a medical reason for why teeth #2 and #14 cannot be extracted. A denture would be less expensive than paying for crowns and other services to restore these teeth.

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. The Plan covers the crowns and posts and cores when the services are medically necessary and reasonable. 

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 crowns and posts and cores. Our reviewer says that the requested services meet the criteria for coverage as they are medically reasonable and necessary. Our physician reviewer found that your dental records and radiographs indicate that these teeth have adequate root canal treatments and good bone support. The remaining upper teeth have adequate bone support and can be restored. Our reviewer does not feel that recommending extractions and a complete denture is in your best interest. Our physician reviewer says the requested services are medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns and posts and cores have been met. Therefore, we decided that the Plan has to pre-approve crowns (D2750) and prefabricated posts and cores (D2954) for teeth #2 and #14.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-covered item or service, recliner chair
component (A9270).

You asked the Plan to pre-approve the non-covered item. You say that you are appealing this denial in order for
the enrollee to receive medical equipment that is medically necessary and there are no providers within 60
miles of the enrollee's home. The Plan denied your request. The Plan says this item is not a covered benefit.

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 the non-covered item or service, recliner
chair component (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).

You asked the Plan to pre-approve the partial denture. You say that your dental provider says that you need several teeth removed as soon as possible to protect your health, and you will need dentures to replace them. You do not think it is fair for you to wait three years to have dentures covered. The Plan denied your request. The Plan says you were previously provided with this same type of partial denture for the upper jaw in 2018. The denture described by code D5213 can only be covered once every 5 years; therefore, this request cannot be pre-approved.

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 partial denture is requested in a frequency not covered under this benefit. Documentation supports that the Plan paid for this same type of partial upper denture and a partial lower denture for you in 2018. In addition, it appears that the Plan has already pre-approved a complete denture for the lower jaw. The denture requested for the upper jaw is still a partial denture and the same type that was provided less than five years ago. Therefore, we decided that the Plan does not have to pre-approve the partial upper denture (D5213).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 29, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says assistant surgeons are not covered.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 13101 and 13102. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heart monitor to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve a heart monitor. You say that the requested provider has better heart
monitors than the in-network providers. The Plan denied your request. The Plan says this is available innetwork.
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 heart monitor to be
provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

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 step therapy criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

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 step therapy requirement 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has severe plaque psoriasis and a history of diabetes and prostate cancer. He has not tried and failed the Plan's required drugs, oral therapy and Inflectra or Renflexis. The records do not show that the required drugs would be contraindicated or less effective; therefore, Ilumya is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam image capture (D0367) and surgical removal of an impacted tooth (D7230) for teeth #1, #16, #17 and #32.
You asked the Plan to pre-approve the dental services. You say that these services are necessary, and these teeth urgently need to be removed. The Plan denied your request. The Plan says these services are not covered by your 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 cone beam image capture (D0367) and surgical removal of an impacted tooth (D7230) for teeth #1, #16, #17 and #32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency, non-ambulance transportation trips.
You asked the Plan to provide coverage for additional non-emergency, non-ambulance transportation trips. The Plan denied your request. The Plan says the evidence shows that the enrollee has used the six (6) one-way trips this year (2021). Additional trips in excess of six (6) one-way trips are non-covered by the health Plan.
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 six (6) one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that you have used the maximus number of trips this year. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergency, non-ambulance transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Januvia.

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 self-administered drugs are not covered.

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 Januvia.

Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement Group 2 power wheelchair (PWC).
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 your current wheelchair can be repaired.
The Plan must follow Medicare rules. Medicare rules say that DME may be replaced only in cases of irreparable damage or when it has surpassed the reasonable lifetime period. We looked at the file and Medicare rules. The file shows that you were approved for a PWC on March 15, 2019 that is not irreparably damaged or more than five years old. 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 replacement Group 2 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sleep number bed, power or manual (A9270).

You asked the Plan to pre-approve the sleep number bed. You say that the enrollee had major back surgery and is still under physical therapy. This bed would make it so it can be adjustable to the contour of his back which would aid to his recovery and continued treatments. The Plan denied your request. The Plan says a sleep number bed is not a hospital bed. This is a comfort or convenience item and is not primarily medical in nature.

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 the sleep number bed, power or manual (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a zoomer scooter.
You asked the Plan to pre-approve a zoomer scooter. You say that you really need the scooter. When you go out in the grass you trip and fall. You can use the scooter to go to your doctor's appointments and when you get tired you can sit down. It can also help you get through the house. The Plan denied your request. The Plan says the records do not show that the enrollee meets the Medicare criteria for the requested item.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that the records provided from the occupational therapist indicates that you are independent with your activities of daily living and your cane was sufficient to meet your mobility deficit needs. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a zoomer scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pre-approve the compression stockings. You say that you feel that this should be a covered benefit to reduce the fluid retention around your legs. You are unable to afford $200 every 6 months for the wraps. The Plan denied your request. The Plan says the records do not support that the enrollee has a qualifying wound therefore this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6565 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6565.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical procedure to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the surgical procedure. You say that it is medically necessary for the
enrollee to undergo care at the out of network facility. The Plan denied your request. The Plan says they have
in network providers that can provide this 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 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 the
surgical procedure to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement oxygen concentrator.

You asked the Plan to pre-approve a replacement oxygen concentrator. You say that you feel this item should
be covered. The Plan denied your request. The Plan says the requested item is not a covered benefit.

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 the enrollee has a current portable oxygen system that was rendered in November 2017.
The enrollee's current portable oxygen system serves the same purpose as the requested portable oxygen
system. The reasonable useful lifetime for oxygen equipment is 5 years. Five (5) years has not passed since the
enrollee last received a portable oxygen concentrator. Therefore, we decided that the Plan does not have to preapprove
a replacement oxygen concentrator.