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

We decided that the Plan does not have to pre-approve facet joint injections.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that facet injections are covered when specific criteria are met. 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 records show that you have chronic low back pain, hip pain, and pain in both legs. Some of the pain is attributed to the sacroiliac (SI) joint. You had an epidural steroid injection that did not provide any pain relief. There is no documentation of a trial of conservative therapy, such as physical therapy or chiropractic therapy. Further, there are multiple possible pain generators present. The requested injections are therefore not reasonable or medically necessary at this time. 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 facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tikosyn for the enrollee.You asked the Plan to pre-approve Tikosyn. You say that this is medically necessary.The Plan denied your request. The Plan says that this medication is not covered under Part B.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-approveTikosyn for the enrollee.Benefits for Tikosynmay be available under Medicare Part D.Contactthe 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 an ultra-lightweight wheelchair.
You asked the Plan to pre-approve an ultra-lightweight wheelchair. You say that you need a new wheelchair. The Plan denied your request. The Plan says that there is no information to indicate that you need this device to accomplish the mobility related activities of daily living.
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 an ultra-lightweight wheelchair. Our reviewer says that an ultra-lightweight wheelchair is not medically reasonable and necessary in this case. The provided medical records do not provide support that you meet criteria for a manual wheelchair. Our physician reviewer found your condition does not meet Medicare criteria for this item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultra-lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrolleehas a diagnosis of rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement. The records show that she has not tried and failed the plan's required drugs of Remicade or Inflectra and Simponi Aria. The records do not support that the required drugs would be less effective or contraindicated; therefore, Orencia is not reasonable or medically necessary at this time.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-approveOrencia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided to the enrollee on June 11, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the records do not support the services.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure
Coding System (HCPCS) code E0466-RR (1 Unit) remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Of note, the delivery ticket submitted is dated June 17, 2019 and the billed date of service is June 11, 2019. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided to the enrollee on June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390) provided to the enrollee on August 22, 2019.You asked the Plan to pay forthe oxygen concentrator. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. Welooked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. A/B MACs (HHH) and DME MACs pay claims for maintenance and servicing fees after 6 months have passed from the end of the final paid rental month or from the end of the period the item is no longer covered under the supplier's or manufacturer's warranty, whichever is later. Healthcare Common Procedure Coding System (HCPCS) code E1390 MS (1 Unit) remains not supported. A review of the patient's claim history shows that this patient has previously received HCPC code E1390 RR from you on date of service June 22, 2019. This is prior to the 6 mos. which Medicare determines is the reasonable period for the maintenance of the equipment.Therefore, we decided that the Plan does not have to pay foroxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390) provided to the enrollee on August 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveback surgery.You asked the Plan to pre-approvethe surgery. You say that this is medically necessary, as you don't want to get put on Oxycodone.The Plan denied your request. The Plan says there are no medical records showing failure of the present treatment plan.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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not support the need for surgery. The exam does not show neurological deficit and you have documented good pain relief with injection. Surgery is not needed at this time.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approveback surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pair of therapeutic depth shoes.

You asked the Plan to pre-approve diabetic shoes. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these shoes is correct, because the Plan did not receive records from the doctor about the enrollee's foot problems or high blood sugar care.

The Plan follows Medicare rules. Medicare rules say that therapeutic shoes for persons with diabetes are only covered when certain specific criteria have been met.

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 diabetic shoes. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested diabetic shoes. Our physician reviewer found the medical records submitted support that this enrollee is diabetic, demonstrates peripheral neuropathy, demonstrates signs and symptoms of poor circulation in both feet, demonstrated foot deformities, and also advises that the enrollee has had previous ulceration to the foot. The documentation does not support that the enrollee is being treated under a comprehensive plan of care for his diabetes. The documentation does not support that the enrollee has had an in-person visit with the physician during which diabetes management is address within 6 months prior to proposed delivery of the shoes/inserts. If this can be established, then the enrollee may be eligible for diabetic shoes. For this reason, the requested diabetic shoes and inserts are not medically reasonable and necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic shoes have not been met. Therefore, we decided that the Plan does not have to pre-approve a pair of therapeutic depth shoes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plan denied your request. The Plan says all services must be received from 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 pre-approve 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 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-approvea referral an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approvethese services. You say that you are falling often and need care.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 submitted records show that you are up as tolerated with a walker. The records do not provide documentation of your functional status or medical necessity of home health aide services. You do not have documented hands-on personal care needs that require a home health aide to maintain your health. There are no identified skilled nursing or skilled rehabilitation needs. The home health aide services are 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-approvehome health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction (D7210), the general anesthesia (D9222), the additional general anesthesia (D9223), and the observation visit (D9430) provided on August 13, 2019.You asked the Plan to pay forthe dental services. You say that the enrollee had a severe tooth infection. You say that it caused issues with the enrollee's state of mind and caused subsequent dehydration. You also say that the oral surgeon did not want to perform the surgery without anesthesia due to the combination of issues.The Plan denied your request. The Plan says the maximum allowance has been reached.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 maximum allowance has been reached. The record shows the Plan paid $170 for services received on April 25, 2019, $147.60 for services received on May 22, 2019, $198 for services received on June 5, 2019, and $34.40 for services received on August 13, 2019.Therefore, we decided that the Plan does not have to pay forthe extraction (D7210), the general anesthesia (D9222), the additional general anesthesia (D9223), and the observation visit (D9430) provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxtellar XR 300mg tablet.
You asked the Plan to pre-approve Oxtellar XR 300mg tablet. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Oxtellar XR 300mg tablet.
Benefits for Oxtellar XR 300mg tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam performed on September 25, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that your EOC says there would be a $0 copay for the exam. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 claim was submitted with the following diagnoses: age-related nuclear cataract, bilateral (H25.13), pinguecula, bilateral (H11.153), myopia, bilateral (H52.13), unspecified astigmatism, bilateral (H52.203) and presbyopia (H52.4). The claim was not routine in nature. You are asked to pay a $45 copayment for the exam. 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 eye exam performed on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) or the comprehensive oral evaluation (D0150) provided on August 29, 2019.You asked the Plan to pay forthe cleaning (D1110) and the comprehensive oral evaluation (D0150). You say that you were approved for these services. You say the provider was told that the services would be covered.The Plan denied your request. The Plan says services done by an out-of-network dentist are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network services are not among those covered under this benefit. The record shows the provider was out-of-network. Therefore, we decided that the Plan does not have to pay forthe cleaning (D1110) or the comprehensive oral evaluation (D0150) provided on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed with mattress and with rails (E0260) to be provided.You asked the Plan to pre-approvethe semi-electric hospital bed. You say that that the medical records provided will show proof of medical necessity.The Plan deniedyour request. The Plan says this enrollee did not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in bodyposition.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 semi-electric hospital bed. Our reviewer says that this semi-electric bed is not medically necessary for this enrollee. Our physician reviewer found the exam does not indicate the member has significant gait abnormality and/or is incapable of self-transfers.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 semi-electric hospital bed have not been met.Therefore, we decided that the 
Plan does not have to pre-approvesemi-electric hospital bed with mattress and with rails (E0260) to be provided
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee is with atrial fibrillation with rapid ventricular response (RVR) and subsequent intracerebral
hemorrhage (ICH) now with challenges regarding rehab and feeding. The enrollee is also with infected pacer
wire and being treated with protracted course of antibiotics.
Based on the documentation provided, 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 Plan. The
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee.
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 admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you cannot fully function on your own and are legally blind. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and panoramic x-ray provided on September 27, 2019.You asked the Plan to pay forthe periapical x-ray and panoramic x-ray. You say that you only have a couple of teeth left that you need pulled so you can get a whole piece on top. You also say that you cannot eat well and almost choke when you eat.The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and panoramicx-ray provided on September 27, 2019.