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

We decided that the Plan does not have to pre-approve the 11 remaining denied extractions (41899) and the
removal of implant (20680).
You asked the Plan to pre-approve the 11 remaining denied extractions (41899) and the removal of implant
(20680). You say that you would like the plan to reconsider your request. The Plan denied your request. The
Plan says the supplemental dental benefit covers only 2 extractions per calendar year. The plan states they will
approve 2 of the requested extractions. The Plan also says the request for removal of hardware on the jaw
(20680) is not a covered benefit under your dental plan.
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 remaining 11 extractions are not
among those covered under this benefit at this time. Your contract says you are only covered for up to 2
extractions per calendar year. The Plan is approving 2 dental extractions. Furthermore, the requested removal
of hardware (20680) is not a covered benefit under Medicare or the Plan's supplemental benefit. Therefore, we
decided that the Plan does not have to pre-approve the 11 remaining denied extractions (41899) and the
removal of implant (20680).
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 needs to get rehabilitation to have a quality of life. You say that the enrollee's wife has chronic issues of her own and cannot take care of him. You say that the enrollee is afraid to go home and that the hospital's geriatrics department agreed that it is unsafe for the enrollee to go home. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The plan says that the enrollee can receive the care needed in another setting, such as home, a long-term care facility, or other outpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, the enrollee does not require the necessary services on 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a routine eye exam and eyeglasses provided on July 31, 2019.
You asked the Plan to reimburse you for the eye exam and the eyeglasses. The Plan denied your request. The Plan says you have exceeded the vision benefits and you must receive these services from a participating provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that you previously received a routine eye exam on April 1, 2019 that was paid by the plan and you previously received a covered pair of eyeglasses on
May 1, 2019. The file shows that the providers at issue in this appeal is not participating providers. Based on this information, we decided that the Plan's rules for coverage of the eye exam and the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for a routine eye exam and eyeglasses provided on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says in-network specialists are available in the area.
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 pre-approved care. 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-approve a referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 13, 2019.You asked the Plan to pay forthe 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 fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 2, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you did not have an appointment with a health care provider. You say that you were only there for blood work. The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for specialist services. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that office visit was for blood work and a skin rash. 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 provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by the out of network
provider.
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 available from network providers.
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 pre-approved care.
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-approve
medical services to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on August 27, 2019.
You asked the Plan to reimburse you for the periodontal maintenance. You say that the provider worded it wrong. You say that you were advised you needed a deep cleaning. You also say that all they did was check your gum and then they did a regular cleaning. The Plan denied your request. The Plan says periodontal maintenance is not a preventive dental service. The Plan also says that periodontal maintenance is not included in your 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, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta for the enrollee.
You asked the Plan to pre-approve Nuedexta. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Nuedexta for the enrollee.
Benefits for Nuedexta 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: 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 enrollee needs this level of care.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 he is currently receiving care. All medically necessary care is being provided in the current acute care setting, and the Plan has approved ongoing care. Therefore, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you believe that daily skilled care would be helpful for recovery. The Plan denied your request. The Plan says the therapists in this case are recommending less than daily skilled therapy in the home health setting. There are no daily skilled nursing needs either.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was admitted on 1/16/2020 with lower back pain and right hip pain. Ortho recommended conservative treatment and injections. MRI showed stable fusion from her prior spinal surgery. She is currently ambulating 100 feet with supervision, and 60 feet times two with a wheeled walker and minimal assist. Based on available records, the patient does not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing PT and OT, the records do not support the need for daily therapy.
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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you have severe lymphedema and cannot wear stockings. The Plan denied your request. The Plan says that elastic stockings are not covered because they are non-reusable supply items.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on October 7, 2019.
You asked the Plan to pay for the additional intraoral x-ray. You say that you called the Plan after your visit on September 9, 2019. You say that you were advised the provider was not in network. You say that you found a provider in the same office that was in network. You say that you received x-rays from that provider and they were not covered either. The Plan denied your request. The Plan says the frequency limit for intraoral x-rays has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and intraoral x-rays are a covered service, frequency limit for this service has been exceeded. The record shows that the Plan paid for an intraoral x-ray that you received on October 7, 2019. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on October 7, 2019.Though the Plan offers a dental benefit in excess of Medicare coverage and intraoral x-rays are a covered service, frequency limit for this service has been exceeded. The record shows that the Plan paid for an intraoral x-ray that you received on October 7, 2019. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) provided on October 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee
currently has no skilled nursing needs and is ambulating 225 feet.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
Continued SNF services beyond January 24, 2020 was requested for 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 SNF services. Our physician reviewer found that the enrollee has
pain which needs to be assessed and treated. The enrollee requires oversight of her medical conditions and
medication management. She is at risk for further episodes of aspiration as well as recurrent substance/alcohol
abuse. The enrollee requires physical therapy for progression of her mobility There are skilled needs, but they
do not need to be provided on a daily basis. The enrollee is ambulating greater than household distances, and
performing essential activities of daily living without hands on assistance. The enrollee's condition would not
be expected to deteriorate with services provided on a less than daily basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4246) provided on September 5, 2019.
You asked the Plan to pay for the dental service. You say that you called the Plan to check if the dentist office was in network and to see what they pay for. You say that you were advised an x-ray, evaluation, and cleaning were paid for. You also say that you have no extra money and cannot afford the bill. The Plan denied your request. The Plan says the dental service you received 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 scaling in presence of generalized moderate or severe gingival inflammation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4246) provided on September 5, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia injections.
You asked the Plan to pre-approve the Prolia injections. You say that Prolia treatment cannot be safely stopped due to the risk of rebound vertebral fracture with medication discontinuation. You say that the change in the enrollee's insurance formulary is an unacceptable reason for medication discontinuation and puts the enrollee at an increased risk. The Plan denied your request. The Plan says that zoledronic acid is appropriate for use before using Prolia.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Prolia injections. Our reviewer says that the criteria for coverage of the requested drug have been met. Our physician reviewer found the plan requires a trial of the drugs oral bisphosphonate and zoledronic acid before they will approve Prolia injections. While the enrollee has failed treatment with Fosamax and Forteo, she has not been treated with zoledronic acid. However, following the enrollee's treatment with Forteo, she was initiated on anti-resorptive treatment with Prolia in December of 2019. The enrollee is due for her second injection in June of 2020. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollee's that are not actively receiving the affected medication. The records support that the enrollee had actively started a course of Prolia and, therefore, step therapy may not be applied 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 the Prolia injections have been met. Therefore, we decided that the Plan has to pre-approve Prolia injections.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Tubigriptubular bandage provided on June 24, 2019 and September 10, 2019 by the out of network provider.You asked the Plan to reimburse you forthe medical supplies. You say that the Plan told you that they needed doctor information and receipts and you would be reimbursed 80%.The Plan denied your request. The Plan says you did not request prior authorization and records do not show any contact from you prior to the purchase.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 reimburse you 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 has network providers available who can provide 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 reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you forthe Tubigrip tubular bandage provided on June 24, 2019 and September 10, 2019 by the out of network provider.