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

We decided that the Plan does not have to pre-approve a referral out-of-network for an audio evaluation and speech recognition for the enrollee.

You asked the Plan to pre-approve the referral. You say that the enrollee has been a patient at this facility for over a decade for treatment of alpha thalassemia and iron overload. The Plan denied your request. The Plan says there are in-network providers available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 pre-approve the referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found the enrollee has been receiving annual audiograms to monitor for toxicity related to chelation therapy. This audiogram testing can be performed at any facility that performs hearing tests with an audiologist. Her medical condition does not require her to see a specific audiologist. Continuity of care is important, but fortunately, audiograms from multiple facilities can be compared to monitor her hearing.

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for an audio evaluation and speech recognition for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

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 the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrocodone-acetaminophen (J8499).

You asked the Plan to pre-approve hydrocodone-acetaminophen. You say that the drug is medically necessary. The Plan denied your request. The Plan says the requested drug is self-administered.

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 hydrocodone-acetaminophen (J8499).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0428, A0425).

You asked the Plan to pay for the ambulance transportation. You say that the transportation was medically
necessary. The Plan denied your request. The Plan says the transport is not eligible for separate payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code A0428, A0425 is not supported in the medical record. Specifically, the record shows
the enrollee was an inpatient at the time the transportation was provided. Ambulance services used for the
transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is
considered part of the inpatient admission. Based on this information, we decided that Medicare rules for
coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have
to pay for ambulance transportation (A0428, A0425).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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 criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The records show that you do not check your blood sugar levels four or more times per day or that you take insulin injections three times per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the facility.

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 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 subsequent nursing facility care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy services but based on the medical records provided, he does not require an intensive inpatient rehabilitation therapy program. Additionally, based on the enrollee's functional and cognitive limitations, there is concern that he will not be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the remaining cost share for the incomplete root canal (D3332).

You asked the Plan to waive the remaining cost share for the dental service. You say that since the root canal was incomplete, you feel that the remaining balance of $192.50 should be waived. The Plan denied your request. The Plan says comprehensive dental services have a 50% coinsurance. The Plan says that out of network dental providers may bill you for any charges remaining over the allowed amount.

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 dental providers may bill you for any charges remaining over the allowed amount. Therefore, we decided that the Plan does not have to waive the remaining cost share for the incomplete root canal (D3332).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided on July 31, 2020.
You asked the Plan to pay for the lumbar sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee has a lumbar sacral orthosis still under reasonable useful lifetime.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee had a lumbar sacral orthosis (L0650) received on December 12, 2018 at the time the lumbar sacral orthosis (L0650) was received. This lumbar sacral orthosis (L0650) received on December 12, 2018 serves the same purpose as the lumbar sacral orthosis (L0650) at issue. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided on July 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee prosthesis to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea knee prosthesis. You say that you wouldlike the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states the knee prosthesis and requested CPT codes can be provided 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.Therefore, we decided that the Plan does not have to pre-approvea knee prosthesis to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation provided on June 1, 2020.
You asked the Plan to pay for the bone replacement graft. The Plan denied your request. The Plan says this procedure is 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 for the bone replacement graft for ridge preservation provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvelower limb prosthesis L5968 with an advanced foot and ankle system (L5981) to be provided.You asked the Plan to pre-approvethe lower limb prosthesis with advanced foot and ankle system. You say that the enrollee meets the definition of a functional level K3 amputee.The Plan denied your request. The Plan says that this request does not meet Medicare criteria as reasonable and necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the lower limb prosthesis with advanced foot and ankle system. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found records from the prosthetist document she is a functional level K3, and the physician's prescription agrees with this functional designation. Medicare coverage criteria have been met based on the enrollee's current functional level (K3) and her potential functional ability. Therefore, this request for a prosthesis with an advanced foot and ankle feature is medically reasonable and necessaryWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lower limb prosthesis with advanced foot and ankle system have been met.Therefore, we decidedthat the Plan has to pre-approvelower limb prosthesis L5968 with an advanced foot and ankle system (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue.

You asked the Plan to pre-approve the localized delivery of antimicrobial agents. You say that you have a lot of pain in your gums and started taking pain medication to alleviate the pain. You say that you have loose teeth and braces. You say that you want to take the braces out. The Plan denied your request. The Plan says the service being requested 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 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeloda.

You asked the Plan to pre-approve Xeloda. You say that the requested drug is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the requested drug is for treatment of breast cancer. The Plan says that the medical records show you are in a clinical trial and that the requested drug is a routine cost which would be covered by Medicare directly.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Xeloda as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. The medical records show that use of the Xeloda is associated with the clinical trial the beneficiary is enrolled in. Therefore, we decided that the Plan does not have to pre-approve Xeloda.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you had a medical emergency but did not wish to be admitted to the hospital. The Plan denied your request. The Plan says you were not admitted to the hospital, therefore the correct cost share has been applied to the claim.

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 $90 copayment for emergency care.

You have been asked to pay a $76.59 copayment for the emergency room visit. This visit falls within the emergency care benefit category. The record indicates that you were not admitted to the hospital for this condition within 3 days of the emergency room visit. 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 emergency room visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions to be provided by an out-of-network provider.

You asked the Plan to pre-approve the tooth extraction. You say that the member needs to have the extractions quickly to avoid further complications and relieve the member's pain. The Plan denied your request. The Plan says there are no exceptions that apply to the member to cover out-of-network dental 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, the requested items or services are not among those covered under this benefit. Services of an out-of-network dentist are not covered. Therefore, we decided that the Plan does not have to pre-approve tooth extractions to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and fundus photography with interpretation
and report services provided by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit and fundus photography with interpretation and report. You say
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
received are not a covered benefit.

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit and fundus photography with
interpretation and report services provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Lite Test in Vitro Strip and Freestyle LancetsYou asked the Plan to pre-approvethe Freestyle diabetic testing equipment. You say that the enrollee was already using this product.The Plan denied your request. The Plan says the documentation must show that the patient has tried a preferred glucose test strip/disk product.The Plan must follow Medicare rules. Medicare rules say that you must try and fail a preferred glucose test strip/disk product that is covered by your Medicare Advantage plan. You may not have to try these products if your prescriber states that you cannotuse these products for medical reasons. The preferred products that are covered by your plan include: Ascensia, Bayer, Contour, One Touch.We looked at the file and Medicare rules. There was no reason given why the enrollee could not use the Plan preferredproducts. Based on this information, we decided that Medicare rules for coverage of the Freestyle diabetic testing equipment have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Lite Test in Vitro Strip and Freestyle Lancets
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient surgery, the laboratory work
and the ECG.

You asked the Plan to waive the copayments for the outpatient surgery, the laboratory work, and the ECG. You
say that you had these services done while you were having surgery and while in observation. The Plan denied
your request. The Plan says you have been charged the correct cost sharing amount.

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 $275
copayment per visit, per provider, per day for surgery performed in an in-network outpatient hospital and a $30
copayment for in-network Medicare-covered laboratory services and diagnostic procedures/tests performed in
an outpatient hospital facility.

You have been asked to pay a total of $324.07 copayment for the outpatient surgery, the laboratory work and
the ECG. The outpatient surgery, the laboratory work and the ECG fall within the "Outpatient hospital
services" benefit category. See chart provided.

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 copayments for the outpatient surgery, the laboratory work and the ECG.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental sealant application (D1354).

You asked the Plan to pay for the dental sealant application. You say that the services were medically necessary. The Plan denied your request. The Plan says this service was 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 pay for a dental sealant application (D1354).