Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 skilled nursing visits.
You asked the Plan to pre-approve the home health services. You say that you are very forgetful. You say that you cannot do anything without daily help. The Plan denied your request. The Plan says the skilled nursing visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has documented skilled nursing needs. Therefore, the reviewer found that the requested home health skilled nursing services are not shown to be medically necessary or reasonable. 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 home health services have not been met. Specifically, the enrollee does not have any skilled nursing needs. Therefore, we decided that the Plan does not have to pre-approve 60 skilled nursing visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the clinical crown lengthening (D4249).
You asked the Plan to pre-approve the clinical crown lengthening (D4249). You say that you are not in a position to pay for the crown installation which is necessary. You say that you only used $723 of your benefit last year and the crown should be paid. 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 the clinical crown lengthening (D4249).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is still being studied in clinical trials for efficacy in the treatment of knee pain.
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 genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. The review has determined that the requested genicular nerve radiofrequency ablation of the right knee is 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve ambulance transport services.
You asked the Plan to pre-approve the ambulance transport services. You say that the enrollee is home with a tracheostomy tube and is needing it changed, which cannot be done by a home health provider. The appellant says that the enrollee cannot get out of bed and requires a Hoyer lift to get into a moving vehicle. The appellant says that the enrollee is unable to get up and walk. The appellant says that the enrollee cannot sit up for longer than 40 minutes. The appellant says that the enrollee's only option to get his tracheal intubation changed is to go by ambulance to his doctor's office, where they have the proper equipment. The appellant says that the clinical documentation provided supports the medical necessity of the requested transportation services. The Plan denied your request. The Plan says that ambulance services to a physician's office is not a covered benefit.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance transport services. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is at home with a tracheostomy tube and is needing it changed. This cannot be done by home health. It is also noted that he cannot sit up for longer than 40 minutes. The enrollee's presenting symptoms meet prudent layperson criteria for emergency care. It is medically necessary for the enrollee to receive ambulance transport to the physician's office. 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 ambulance transport services have been met. Therefore, we decided that the Plan has to pre-approve ambulance transport services.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 26, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you had a stroke, and you were "laid up" for 3-4 weeks and had to exercise to try to get your leg working. You say that your leg is working again but every now and again it gets weak, gives out, and you fall on the floor and you are not able to pick yourself up and you do not have anyone close to come and help and your wife had heart surgery and is unable to lift you. You say that is why you called the ambulance, and they lift you up and check you. The Plan denied your request. The Plan says per CMS guidelines the ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

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 pay for ambulance response and treatment, no transport. Our reviewer says that ambulance response and treatment, no transport does not meet Medicare coverage criteria. Our physician reviewer found that you fell and were treated by emergency medical services (EMS). You were found alert and required help to get back up. You had weakness due to recent prolonged hospitalization related to a stroke. Your physical exam and vitals were stable. You refused transport to the hospital. Based on the provided documentation, you do not appear to meet the CMS "treat in place" COVID-19 protocols for medically necessary ambulance services as you were stable and refused ambulance transport. 

The ambulance company did not provide transport services on February 26, 2021. 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 for ambulance response and treatment, no transport (A0998) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921).

You asked the Plan to pre-approve gingival irrigation (D4921). You say that without the irrigation the actual deep cleaning would not be able to be performed. You say that due to your pre-existing condition you are required to be vigilant with any bacterial infection due to dental work as instructed by your surgeon. 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 gingival irrigation (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oncology office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an OON oncology office visit. You say that you would like an outside opinion. The Plan denied your request. The Plan says this is available 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 an oncology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital detoxification.
You asked the Plan to pre-approve inpatient hospital detoxification. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you can be treated in a less restrictive level of care.
The Plan follows Medicare rules. Medicare rules state that inpatient hospital detoxification may be covered under certain circumstances. 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 inpatient hospital detoxification.
Our reviewer says that you do not meet the Medicare criteria for the requested inpatient hospital detoxification service. Our physician reviewer found it is not expected that you would improve in a reasonable period of time as you do not have dangerousness to self or others, auditory or visual hallucinations, delusions, and were not showing any aggressive behavioral issues. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital detoxification have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital detoxification.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). You say that you are suffering from blood pressure conditions. The Plan denied your request. The Plan says the certification from your physician dated July 14, 2021, documented that you have a cardiovascular disorder (hypertensive disease and pericarditis) but you do not require intense care coordination, and you have no high risk for hospitalizations or high risk for
adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs)
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with Coronavirus pneumonia and respiratory distress requiring high flow oxygen support. A tracheostomy was placed. She does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. The LTACH services are therefore 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need this to rebuild strength and endurance. The Plan denied your request. The Plan says you can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have identifiable skilled nursing or therapy service needs. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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 is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).

You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that your previous dentures are uneven. You say that you have trouble eating and you feel a lot of pressure when you push down on the dentures. The Plan denied your request. The Plan says the service requested by your dentist is only covered one time in a 60-month 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one complete upper and lower denture every 60 months. The Plan paid for an upper and lower denture provided on December 17, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says your request exceeds the 50 miles allowed per one-way transportation 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. The Plan covers a maximum of 36 one-way transportation trips per year, not to exceed 50 miles per one-way trip.
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a total of 125 miles per one-way trip, which exceeds the 50 miles per one-way trip allotted by the Plan's supplemental routine transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional mileage
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture.
You asked the Plan to pre-approve the upper partial denture. You say that your health is being affected by not being able to chew food well and you bite your lips. You say that you lost your bridge on a trip and are requesting reconsideration. The Plan denied your request. The Plan says this service is limited every five years after date of insertion.
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, you also have a maximum benefit of one upper partial denture every 5 years. The Plan paid for an upper partial denture provided on October 18, 2016, which exhausted your benefit. Contact the Plan regarding when your denture benefit is available again. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical services to be provided at the in-network benefit level by an out-of-network (OON) provider.

You asked the Plan to pre-approve surgical services. You say that this provider has been ranked as a center of excellent and has a vast amount of resources to care for this highly complex patient. The Plan denied your request. The Plan says the denial of authorization for in-network coverage for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 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 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 at the in-network benefit level. The enrollee's POS benefit does cover out-of-network hospitalization or outpatient surgery with Plan approval. Please contact the Plan for more information about utilizing the POS benefit for these services. Therefore, we decided that the Plan does not have to pre-approve surgical services to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950).
You asked the Plan to pre-approve core buildup (D2950). 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 core buildup (D2950).