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

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1833, L2397) provided to the enrollee on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350 x 4) provided on September 19, 2019.
You asked the Plan to pay for the dental service. You say that you do not understand why the services are not covered if you need them. The Plan denied your request. The Plan says the dental service is not listed as a covered service.
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, the2 D oral or facial photographic imaging is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350 x 4) provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you were prescribed compression
stockings due to venous issues in your legs. The Plan denied your request. The Plan says compression
stockings A6530 are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on October 3, 2019.You asked the Plan to pay for the dental service. You say that you do not have money to pay for the service. You say that the dentist did a check-up and recommended certain things. You also say that you asked if Medical covered the service and you were advised "yes".The Plan denied your request. The Plan says the dental service you received is not listed as 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 topical application of fluoride varnish is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe topical application of fluoride varnish (D1206) provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on August 9, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple extractions.You asked the Plan to pre-approvethe extractions. You say that any dental procedure rendered to this enrollee should be considered medically necessary due to his treatments.The Plan denied your request. The Plan says Medicare does not cover these services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrolee's teeth or the structures directly supporting the enrollees teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvemultiple extractions
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay forthe ambulance services. You say that an ambulance was called for you. You say that after treatment you were advised by the responders that you did not need to go to thehospital. After receiving additional treatment, you were advised to eat something before resting and returning to bed.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 6, 2019. 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 forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 11, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior
authorization was not obtained as required under the Plan benefits.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The contract with the Plan says that prior authorization is
required under the POS benefit.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on September 11, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided on September 1, 2019.
You asked the Plan to pay for the nursing facility visit. You say that the services are medically necessary. You say that the claim should be paid whether there is authorization or not. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the nursing facility visit provided on September 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.You asked the Plan to pre-approve Benlysta. You say that the requested Benlysta is medically necessary.The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.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 Benlysta. Our reviewer says that the requested Benlysta is not medically necessary. Our physician reviewer found the enrollee is with auto antibody negative systemic lupus erythematosus. The provided medical records indicate that the enrollee is not auto antibody positive with her systemic lupus erythematosus. The Medicare-approvedcompendia do not contain any citation to support the use of Benlysta for auto antibody negative systemic lupus erythematosus.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Benlysta have not been met.Therefore, we decided that the Plan does not have to pre-approveBenlysta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular
physician evaluation. The enrollee's care needs can be met at 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330), and the intraoral periapical x-ray (D0220) provided on May 28, 2019.You asked the Plan to pay forthe panoramic x-ray. You say that had you been told the x-ray was not covered prior to having it taken, you would not have had it done.The Plan denied your request. The Plan says the panoramic x-ray is not listed as a covered service.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 panoramic x-ray not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330), and the intraoral periapical x-ray (D0220) provided on May 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nulojix (J0485) for the enrollee.
You asked the Plan to pre-approve Nulojix. You say that the enrollee needs this to prevent transplant rejection.
The Plan denied your request. The Plan says that the request does not meet the Medicare rules because the drug
recommended has not been shown to be appropriate and/or safe for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that parenteral belatacept is not proven to be safe
when administered in the home setting and therefore will be denied as not medically necessary when provided
in that setting.
We looked at the file and Medicare rules. The file indicates this drug is being requested for home use. Based on
this information, we decided that Medicare rules for coverage of Nulojix have not been met. Therefore, we
decided that the Plan does not have to pre-approve Nulojix (J0485) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D52214). You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says partial denture is not listed as a covered service.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 not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea mandibular partial denture (D52214)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered from June 21, 2019 to September 9, 2019.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the diabetic supplies rendered from June 21, 2019 to September 9, 2019.
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-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for necrotizing pneumonia. The enrollee is receiving antimicrobials and her routine hemodialysis. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy No Coding Test Strips.You asked the Plan to pre-approveProdigy No Coding Test Strips. You say that the requested items are necessary.The Plan denied your request. The Plan says the refill requested exceeds the allowed quantity in a 90 day time frame.The Plan follows Medicare rules. Medicare rules say that the quantity of test stripsthat are covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus.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 Prodigy No Coding Test Strips. Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee has type 2 diabetes treated with insulin (basal once daily andrapid acting before each meal). Blood sugar is monitored five times daily. Per pharmacy fill data, 450 test strips were dispensed on December 23, 2019. There is no documentation of any rationale for an early refill of test strips. The medical records do not show that it is medically necessary for the enrollee to receive greater than 450 test strip in 90 days.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prodigy No Coding Test Strips have not been met.Therefore, we decided that the Plan does not have to pre-approveProdigy No Coding Test Strips
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Lumbar-sacral orthosis (L0650) provided February 16, 2019.You asked the Plan to pay forthe orthosis. You say that yo believe this claim should be covered and request reconsideration of the original claim for this claim.The Plan denied your request. The Plan says in order to be eligible for payment, the originating site must be either a physician or practitioner's office, a hospital, a critical access hospital, a rural health clinic, a federally qualified health center, a hospital-based or critical access hospital-based renal dialysis center, a skilled nursing facility (SNF) or a community mental health center.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a ruralcensus tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forLumbar-sacral orthosis (L0650) provided February 16, 2019