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

We decided that the Plan has to pre-approve a Freestyle Libre reader.

You asked the Plan to pre-approve a Freestyle Libre reader. You say that the requested item will provide you with better control of your blood sugar. The Plan denied your request. The Plan says that rules for a Freestyle Libre reader have not been met.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The case record makes clear that the Plan had access to information about your level of insulin use on which they based their decision to deny. We requested this information but it was not provided to us. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre reader.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services described by current procedural terminology (CPT) code 15271 provided on November 5, 2020.
You asked the Plan to pay for CPT code 15271. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 15271.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 15271 is Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. We find that CPT code 15271 is not supported in the medical record. Specifically, the description of this code was not documented in the operative report. Based on this information, we decided that Medicare rules for coverage of CPT code 15271 have not been met. Therefore, we decided that the Plan does not have to pay for the wound care services described by current procedural terminology (CPT) code 15271 provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions - one to
three teeth or tooth spaces, per quadrant (D7311) performed by an oral surgeon.

You asked the Plan to pre-approve the tooth extraction performed by an oral surgeon. You say that it is
medically necessary to have the tooth extraction performed by an oral surgeon. The Plan denied your request.
The Plan says dental services performed by oral surgeons are not covered under your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a tooth
extraction once a year when performed by a participating general dentist.

We looked at the file and Medicare rules. In this case you are requesting services to be performed by an oral
surgeon. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction
performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to preapprove
alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311)
performed by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction for a medical exam provided on
August 20, 2020.

You asked the Plan to pay for the eye refraction for a medical exam. You say that The Plan denied your request. The Plan says the claim processed with the correct cost share.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction for a medical exam provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be rendered by an OON provider.

You asked the Plan to pre-approve the OON dental services. You say that you would like to be approved to receive dental services from an OON provider. The Plan denied your request. The Plan says OON services are not available under your benefit plan. The Plan also says that there are contracted dental providers available for you to receive your dental care.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve dental services to be rendered by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950).
You asked the Plan to pre-approve a core buildup. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service at issue 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 a
core buildup (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36473) and stab phlebectomy of varicose veins (37765).

You asked the Plan to pre-approve these services. You say that the services are medically necessary for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that the treatments to eliminate the saphenous vein reflux will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy and has reflux in a saphenous vein. Additionally, treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are > than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 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 requested services are not medically necessary. Our physician reviewer found that the documentation provided does not meet Medicare criteria and does not support the medical necessity of the treatments in question. There is insufficient documentation provided that the patient is having lifestyle limiting symptoms that are attributable to varicose veins despite the regular use of compression stockings. Furthermore, the provider notes that if there is no saphenous incompetence, the patient would be unlikely to benefit from any surgical procedure; this is the case on the right leg. Symptoms on the left leg are minimal and the greater saphenous vein is nondilated. 

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 endovenous ablation therapy (36473) and stab phlebectomy of varicose veins (37765).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).

You asked the Plan to pre-approve the dental service. You say that the enrollee's previous denture fractured in half. You say that the denture cannot be restored. You also say that the enrollee is having a very difficult time chewing and digesting food properly. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit 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 and partial lower denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial lower denture that you received on December 27, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reclast infusion to be provided at an OON facility.

You asked the Plan to pre-approve the Reclast infusion. You say that you have osteoporosis. You say that is
why your rheumatologist wants you to receive the infusions. You say that your primary care physician (PCP)
wanted you to take pills which you have taken for 3 months but they make you sick. The Plan denied your
request. The Plan says the requested facility is out of network. The Plan also says that your PCP office has
confirmed they are able to provide the requested 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 facility in this case is not a network facility with the Plan. The requesting provider is not your
primary care physician. The Plan has confirmed your primary care physician 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 Reclast infusion to be provided at an OON
facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on January 14, 2021.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that your prior dental insurer determined it was medically necessary for you to receive more frequent routine dental treatments. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on January 14, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft replacement (D6104), custom abutment (D6057) and gum surgery (D4266) for tooth #18.
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone graft replacement (D6104), custom abutment (D6057) and gum surgery (D4266) for tooth #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular
partial denture (D5212).

You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that
you need these dentures to be approved for coverage. The Plan denied your request. The Plan says these
services are allowed one time in 5 calendar years. The Plan also says that you have already received these
services within the past 5 years, and have reached the limits for these services.

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, complete maxillary denture (D5110)
and is limited to 1 of either codes D5110, D5211, or D5213, or D6110, or D6112 per 5 calendar years, and
mandibular partial denture (D5212) is limited to 1 of either codes D5120, D5212, or D5214, or D6111, or
D6113 per 5 calendar years. The record shows that you received a maxillary partial denture (D5211) and a
mandibular partial denture (D5212) on September 9, 2017, and your maxillary and mandibular denture benefits
have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary
denture (D5110) and a mandibular partial denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, 60 mg/ml syringe.

You asked the Plan to pre-approve the Prolia. You say that the enrollee has a history of Barrett's Esophagus and is taking medication for GERD daily. You also say that there are contraindications of taking Alendronate with Barrett's Esophagus. The Plan denied your request. The Plan says there is no indication that the enrollee has had an osteoporosis-related fracture. The Plan also says that there is no evidence that the enrollee has tried and failed zoledronic acid.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Prolia. Our reviewer says that the Prolia is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, zoledronic acid. The reviewer found that the enrollee does not have a history of fracture from osteoporosis. The reviewer also found there is no documentation provided indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia, 60 mg/ml syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating ambulatory center on November 13, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $150 copayment for outpatient surgery/in-network/ambulatory surgical center. You have been asked to pay a $150 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network/ambulatory surgical center 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 an outpatient surgery provided by a participating ambulatory center on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, CT scan and related services provided by an out-of-network provider on January 6, 2021.

You asked the Plan to pay for the office visit, CT scan and related services. You say that the medical records support the level of care rendered in good faith and the claim should be reviewed for retro-authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.

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 the office visit, CT scan and related services. Our reviewer says that the coverage rules are not satisfied. Our physician reviewer found that once the enrollee was discharged from the hospital, an emergent or urgent situation no longer existed. Our reviewer says that the services could have been sought from an in-network provider without jeopardy to the enrollee's health.

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 office visit, CT scan and related services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit, CT scan and related services provided by an out-of-network provider on January 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided on January 1 to January 26, 2020, and on January 31 to February 12, 2020.
You asked the Plan to waive the copayment for SNF care. You say that the requested care was a necessity for the enrollee. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $178 copayment per day of days 21-100 of SNF care. The enrollee has been asked to pay $5,518, or a $178 copayment per day for 31 days of SNF care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF care provided on January 1 to January 26, 2020, and on January 31 to February 12, 2020.
Your appeal also involves a complaint about the Plan's distribution of copayments over the days of provided SNF care. You say that the enrollee's supplemental policy is unable to provide coverage if the Plan's Explanations of Benefits do not reflect the chronology of care. This complaint is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.