Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that Prolia is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan follows Medicare rules. Medicare rules say that for Prolia to be covered, a record of using Supplemental calcium and vitamin D is required.We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the provided medical records do not document that the enrollee is receiving supplemental calcium and vitamin D and there is no evidence of hypocalcemia or that hypocalcemia has been corrected prior to initiation of Prolia therapy.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnsure milkshake supplements.You asked the Plan to pre-approveEnsure milkshake supplements. You say that you need these supplements to nourish yourself.The Plan denied your request. The Plan says these supplements are not covered.The Plan must follow Medicare rules. Medicare rules say that nutritional supplementation is not covered under Medicare Part B.We looked at the file and Medicare rules.The requested supplements are not covered.Based on this information, we decided that Medicare rules for coverage of Ensure milkshake supplements have not been met.Therefore, we decided that the Plan does not have to pre-approveEnsure milkshake supplements.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued chiropractic services.
You asked the Plan to pre-approve the services. You say that there continues to be chronic pain. The Plan denied your request. The Plan says it was determined that there is no subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 services Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the only treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be demonstrated by x-ray or by physical examination. The submitted imaging report of the lumbosacral spine, dated 11/29/19, reveals normal vertebral height and alignment, facet arthropathy at L4-5, mild degenerative changes of the lower lumbar spine without appreciable change from comparison examination. There is also endplate spurring at L3-5 and disk space narrowing at L4-5. There is no evidence of a subluxation. The remainder of the medical records findings do not reveal evidence of subluxation per the Medicare guidelines. Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 17, 2020.
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your request. The Plan says that there are no medical records showing that the prescribing physician ever saw the member.
The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement arm pads and calf pad covers.
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 items are not covered.
The Plan must follow Medicare rules. The rules say that a Column II code is included in the allowance for the corresponding Column I code when provided at the same time. We looked at the file and Medicare rules. The requested services are gel full length arm pads (K0019), and calf pad covers (E0995). Codes K0019 and E0995 are column II codes to the approved K0856 PWC and are not separately approved. Therefore, we decided that the Plan does not have to pre-approve replacement arm pads and calf pad covers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown, a partial maxillary denture, and a partial mandibular denture.You asked the Plan to pre-approvea crown, a partial maxillary denture, and a partial mandibular denture. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services exceed your benefit limit.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 crown, a partial maxillary denture, and a partial mandibular denture when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Review of the file shows that crowns are only covered at one procedure per tooth every five plan years. You last received a crown for tooth number 22 on October 22, 2018. Five years had not passed since you previously received a crown for this tooth. Partial dentures are covered once every five plan years. You previously received service on your partial dentures on November 26, 2019. Fiveyears had not passed since you previously received these denture services. Based on this information, we decided that the Plan's rules for coverage of a crown, a partial maxillary denture, and a partial mandibular denture have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown, a partial maxillary denture, and a partial mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection and expandable controller with harness.
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. Medicare rules say that an electronic connection and expandable controller with harness are covered when specific criteria are met.
We looked at the file and Medicare rules. The documentation does not support that the electronic connection and expandable controller with harness are needed to control the approved power options through a joystick. 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 an electronic connection and expandable controller with harness.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home blood pressure cuff.You asked the Plan to pre-approvethe home blood pressure cuff. You say that you are required to check your blood pressure at home and the requested device is medically necessary.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm adiagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approvea home blood pressure cuff
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forportable x-ray services (Q0092, R0070) provided on January 16, 2020.You asked the Plan to pay forportable x-ray services. You say that these are covered services.The Plan denied your request. The Plan says these services are not separately billable from the enrollee's SNF stay.The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separatelybillable to Medicare Part B.We looked at the file and Medicare rules.The record shows that the enrollee was in a Part A SNF stay when the services at issue were provided.Based on this information, we decided that Medicare rules for coverage of portable x-ray services have not been met.Therefore, we decided that the Plan does not have to pay forportable x-ray services (Q0092, R0070) provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic and retainer crown.
You asked the Plan to pre-approve these services. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic pontic and retainer crown.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 16, 2020, by an out of network provider.
You asked the Plan to pay for a magnetic resonance imaging (MRI) scan of the brain stem and a Gadobutrol injection. You say that you are unable to cover the billed amount. The Plan denied your request. The Plan says rules for payment have not been met.
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 medical services provided on January 16, 2020, by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe MRI of an upper extremity (73222).You asked the Plan to pre-approvethe MRI of an upper extremity. You say that you would like reconsideration because this MRI is medically necessary.The Plan denied your request. The Plan says the documentation does not include the results of an x-ray taken after the member's symptoms started or changed.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of an upper extremity. Our reviewer says that the review has determined that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no specific clinical rationale for the requested MRI of the shoulder.  There are no reports of shoulder pain and no abnormal physical exam findings reported.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 MRI of an upper extremity have not been met.Therefore, we decided that the Plan does not have to pre-approvethe MRI of an upper extremity (73222).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating hospital on August 11, 2020.You asked the Plan to waive the copayment foroutpatient hospital services. You say that you do not know why your copayment is so high. 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 $200 copayment for outpatient surgery.You have been asked to pay a $200 copayment for outpatient hospital services. When services are provided in a hospital facility, an outpatient hospital services copayment is applied; therefore, the correct copayment has been applied. Outpatient hospitalservices falls within the outpatient surgery 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 outpatient hospital services provided by a participating hospital on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 3, 2020, by an out of network provider.You asked the Plan to pay fornursing facility care, a trimming of dystrophic nails, and a nail debridement. You say that the provider rendered services to the enrollee in a nursing home setting.The Plandenied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on August 3, 2020, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 25, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the services require authorization.
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 provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by the out-of-network provider.You asked the Plan to pre-approve the power wheelchair. The Plan denied your request. The Plan says youmust receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 power wheelchair. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed with gel mattress pad.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed and support surface are covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you have hypoxia (absence of proper oxygen levels) and weakness. The records do not clearly show that you require positioning of the bed in ways not feasible in anordinary bed or that positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The documentation does not reveal the patient is completely immobile, cannot independently make changes in body position significant enough to alleviate pressure or has a pressure ulcer on the trunk or pelvis. The requested semi-electric hospital bed and gel pressure mattress pad 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 these services have not been met.Therefore, we decided that the Plan does nothave to pre-approvea semi-electric hospital bed with gel mattress pad.
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 you would like reconsideration because there is a
state of emergency and the member is at risk of contracting COVID-19. The Plan denied your request. The
Plan says the member's needs may be met at a lower level of care.
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 is not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. The enrollee's 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab work provided by a participating provider on July 24, 2020.
You asked the Plan to waive the coinsurance for lab work. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 10% coinsurance for outpatient diagnostic tests/laboratory tests. You have been asked to pay a 10% coinsurance of the allowed amount for lab work. The total allowed amount is $115.46. The total amount you are being asked to pay is $11.55 ($115.46 x 10% = $11.55). Lab work falls within the outpatient diagnostic tests/laboratory tests 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 coinsurance for lab work provided by a participating provider on July 24, 2020.