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

We decided that the Plan does not have to pre-approve a grab bar/toilet rail (E0243).
You asked the Plan to pre-approve a toilet rail. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not a Medicare benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar/toilet rail (E0243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a root canal (D3348) provided on December 1, 2020.
You asked the Plan to pay for the dental service. You say that you had a root canal in the 1980s. You say that the tooth had become painful due to an abscess. You say that the dentist had to redo the root canal. You also say that this should be covered. The Plan denied your request. The Plan says retreatment of a previous root canal 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 retreatment of a root canal is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of a root canal (D3348) provided on December 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that you need home health services for your medical condition. Plan denied your request. The Plan says the notes do not show that you have met the conditions for short term healthcare services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation doesn't support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. There are no skin issues and he is at his baseline level of functioning. The requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vertiflex Superion Interspinous device provided to the enrollee on December 28, 2020.
You asked the Plan to pay for these services. You say that you would have requested prior authorization if you knew it was necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of spinal stenosis has not been demonstrated in the peer-reviewed literature.
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 pay for these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for these services. 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 pay for the Vertiflex Superion Interspinous device provided to the enrollee on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DMPK gene analysis testing.
You asked the Plan to pre-approve these services. You say that you need the testing to help with diagnosis. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that DMPK gene analysis is non-covered. We looked at the file and Medicare rules. The services at issue are DMPK gene analysis. This testing is non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve DMPK gene analysis testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a controller with LCD color display, expandable
controller with harness upgrade, electronic connection, and power seat elevation system.
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 covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules say that a power seat elevation system is not covered. The rules say that an
expandable controller with harness upgrade and electronic connection are needed to control three or more
power options.
The requested controller with LCD display does not serve a purpose that is primarily medical in nature and is
therefore not covered. The power seat elevation system is not covered by Medicare for any indication. The
expandable controller with harness upgrade and electronic connection are not needed to control the approved
power switches. Therefore, we decided that the Plan does not have to pre-approve a controller with LCD color
display, expandable controller with harness upgrade, electronic connection, and power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950) and porcelain/ceramic crown for tooth #11.
You asked the Plan to pre-approve a core buildup. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's 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 core buildup (D2950) and porcelain/ceramic crown for tooth #11.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Specifically, there are no medically necessary services offered at the LTACH that the enrollee is not already getting at their current level of care. This means that admission to an LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a gastroenterologist on January 15, 2021.
You asked the Plan to waive the copayment for the gastroenterology visit. You say that you feel you should not have to pay this copayment because the doctor was rude. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for the gastroenterology visit. This copayment applies regardless of your satisfaction with the 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 office visit you had with a gastroenterologist on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inhalation of nitrous oxide/analgesia (D9230).
You asked the Plan to pre-approve the inhalation of nitrous oxide/analgesia. You say that the provider would
rather you use gas because they cannot risk your lungs not opening and closing. The Plan denied your request.
The Plan says this service 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 pre-approve the
inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by 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 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 lab work provided on January 5, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of recurrent cataract procedures you had on January 6, 2021, and January 12, 2021.
You asked the Plan to waive the copayment for the surgical procedures. You say that you were told that these follow-up procedures would be at no cost to you. The Plan denied your request. The Plan says you were charged these copayments correctly. The allowed amount for each of these procedures ($245.47) is less than your copayment obligation, so you are responsible for the full allowed 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 $325 copayment for outpatient surgical procedures.
You have been asked to pay a $325 copayment for the surgical procedures. There is no provision in your contract for a waiver of these amounts if the procedures are follow-up procedures. 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 removal of recurrent cataract procedures you had on January 6, 2021, and January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on January 14, 2021.
You asked the Plan to waive the copayment for hearing services. You say that you thought this was your routine hearing exam and you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for hearing services to diagnostic and treat hearing and balance issues and a $0 copayment for routine hearing services. The record shows that you received hearing services to treat a hearing issue on January 14, 2021. Therefore, the hearing services you received are considered diagnostic, not routine, and you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for hearing services. Hearing services fall within the hearing services 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 hearing services provided on January 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 27, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 physician's services provided on November 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is not safe to discharge to a
home setting, given his poor carryover and insight into his medical conditions. You say that the enrollee
continues to require contact guard assistance for ambulation and transfers, and his cognition and carryover
continue to be a barrier to successful discharge to the home setting. The Plan denied your request. The Plan
says further needed services could be rendered in an outpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and
ophthalmic medications. The enrollee had stable vital signs and clear lungs. The enrollee received physical
therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a supervision to
contact guard/minimal assist level with functional mobility, including gait to 150 feet with a rolling walker.
The enrollee required varying assist with activities of daily living. The enrollee tolerated a regular diet with
thin liquids. There are no identifiable skilled nursing care needs. While there are identifiable skilled therapy
service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or
intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $15 copayment charged for a physician visit provided to the enrollee on December 29, 2020.
You asked the Plan to waive this copayment. You say that the enrollee does not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the Plan contract agreement.
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 $15 copayment for physician visits. 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 $15 copayment charged for a physician visit provided to the enrollee on December 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Erbitux.
You asked the Plan to pre-approve Erbitux. You say that there are a number of case reviews showing potential benefit to a drug like Erbitux. The Plan denied your request. The Plan says the denial of authorization for Erbitux is correct, because studies have not proven that this drug is helpful in the enrollee's circumstances.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Erbitux. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Erbitux. Our physician reviewer found the record indicates that the enrollee has Stage IV rectal cancer and has progressed on treatment that included Vectibix. The enrollee has an ascending colon mass and liver lesions from his rectal cancer. The enrollee has been seen at different institutions and different plans are noted in the records. No genomics analysis is available for review. The records are insufficient to establish the regimen being requested. Only case report evidence has been submitted for the use of Erbitux.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Erbitux.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from March 12, 2020,
to November 17, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you have been getting treatment for
your Fibrosis with a specialist in Mexico. You also say that you are reluctant to return to the US because you
were told your fibrosis is not curable, and you have an oxygen device that does not allow you to travel. The
Plan denied your request. The Plan says your primary care physician (PCP) says that you have been living out
of the US for over one year. The Plan also says that your records in 2019 show that you were receiving care
within network.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided from March 12, 2020, to November 17, 2020.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit provided on January 19, 2021, by an OON
provider.
You asked the Plan to pay for a rest home visit. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says in all assisted living facility services scenarios, the out of network
provider would be responsible for securing a prior authorization. The Plan says that prior authorization was not
obtained.
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 a rest home visit provided on January 19, 2021, by
an OON provider.