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

We decided that the Plan does not have to pre-approve the incision for implantation of neurostimulator electrode array, sacral nerve (transforaminal placement) (64581).
You asked the Plan to pre-approve the sacral nerve stimulation. You say that you are requesting this information be evaluated and reconsider the approval of implantable neuromodulation therapy. The Plan denied your request. The Plan says this procedure is considered investigational and experimental and therefore not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sacral nerve stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve the incision for implantation of neurostimulator electrode array, sacral nerve (transforaminal placement) (64581).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88312) rendered by the out-of-network (OON) provider on January 25, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88312) rendered by the out-of-network (OON) provider on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs or medicaments dispensed in office for home use (D9630), and topical application of fluoride varnish (D1206) provided on April 15, 2021.
You asked the Plan to pay for drugs or medicaments dispensed in office for home use, and topical application of fluoride varnish. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 drugs or medicaments dispensed in office for home use (D9630), and topical application of fluoride varnish (D1206) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composite (D2331) provided on May 20, 2021, and June 1, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and resin-based composite. You say that the Plan stopped covering services rendered by OON providers without notification to you. You also say that you stayed with this insurance plan because they offered coverage with OON dental providers in October 2020. The Plan denied your request. The Plan says you must receive services at a participating provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and resin-based composite (D2331) provided on May 20, 2021, and June 1, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that IVIG is 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 the services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of polyneuropathy. There is no documentation to support that the criteria for coverage of Gamunex are met. The services are not reasonable or medically necessary to treat your condition.
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 pre-approve Gamunex.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary immediate denture (D5130), mandibular partial denture (D5214), four extractions (D7140 x4), and alveoloplasty in conjunction with extractions (D7310) provided on April 13, 2021.
You asked the Plan to pay for the maxillary immediate denture, mandibular partial denture, extractions, and alveoloplasty. You say that you cannot afford to pay for all of these services by yourself. The Plan denied your request. The Plan says these services are not covered benefits under your 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 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 maxillary immediate denture (D5130), mandibular partial denture (D5214), four extractions (D7140 x4), and alveoloplasty in conjunction with extractions (D7310) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medication assisted treatment provided from August 27, 2020, through November 25, 2020.

You asked the Plan to pay for medication assisted treatment. The Plan denied your request. The Plan says there is no record of a prior authorization being obtained from the member's primary care physician.

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 medication assisted treatment provided from August 27, 2020, through November 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 IRF admission and services.
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 are requesting coverage of the 
compression stockings. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 panoramic x-ray (D0330) provided on April 6, 2021.
You asked the Plan to pay for the dental service. You say that you had to change dentists because your old dentist no longer accepted hour insurance. You say that you asked for your records to be transferred to the new dentist. You also say that the panoramic x-ray was not transferred so you needed to have a new one done. The Plan denied your request. The Plan says 1 panoramic x-ray is covered in a 36 month period. The Plan also says that the frequency limit 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 panoramic x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on July 15, 2020, less than 36 months prior. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on December 26, 2020 by an OON provider.
You asked the Plan to pay for the home visit. You say that you provide urgent/emergent care in the home which does not require prior authorization, nor does it require a referral. You also say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says these services were not rendered by network/primary care providers. The Plan also says that when services are performed by a non-participating provider, the service is not covered by the enrollee's 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 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 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 home visit provided on December 26, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses provided on January 27, 2021.
You asked the Plan to pay for the contact lenses. You say that you have $200 benefit coverage per year for contact lenses or eyeglasses. You say that contact lenses are clearly covered in the benefits book. The Plan denied your request. The Plan says this provider is a non-participating provider and you only have in-network benefits.
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. The Plan covers these services when they are received from a network provider. 
We looked at the file and the Plan's rules. The contact lenses were received from a non-participating provider. Vision services are only covered when received from a network provider. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 19, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no authenticated medical records from the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.
We find that the lab testing is not supported in the medical record. The records provided do not show that the testing was ordered to treat a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure cuff.
You asked the Plan to pre-approve a blood pressure cuff. You say that you need to monitor your blood pressure closely. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity of a blood pressure cuff.
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 a diagnosis 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-approve a blood pressure cuff.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin graft Novafix procedure.
You asked the Plan to pre-approve skin graft Novafix procedure. You say that this requested procedure is medically necessary for your medical condition. The Plan denied your request. The Plan says you have not shown a failed response to wound care measures.
The Plan follows Medicare rules. Medicare rules say that in order for skin substitutes to be covered, the enrollee must have a failed response to wound 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 skin graft Novafix procedure. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found you are a 62-year-old female with a non-pressure chronic ulcer. In this case, the records do not show that you have tried and failed at least 30 days of standard wound care based on consecutive weekly wound measurements. Per the documentation, the wound is improving and reducing in size. The review has determined that you do not have a covered indication for the requested procedure. Specifically, there is no evidence that you have failed response to wound care measures as specified by the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin graft Novafix procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve skin graft Novafix procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete series of radiographic images (D0210) provided on April 12, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and a complete series of radiographic images. You say that you were not aware that the provider was out-of-network, and you thought the services would be covered. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and a complete series of radiographic images have not been met.
Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), and a complete series of radiographic images (D0210) provided on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a negative pressure wound therapy (NPWT) pump.
You asked the Plan to pre-approve NPWT pump. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this device is correct, because the enrollee does not meet criteria.
The Plan follows Medicare rules. Medicare rules state that negative pressure wound therapy (NPWT) pumps may be covered under certain clinical criteria.
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 NPWT pump. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of a negative pressure wound therapy pump. Our physician reviewer found the documentation support the medical necessity of the device in question, and the enrollee meets all coverage criteria. This is a surgical wound for which the prescribed therapy is better than any other available option. There is satisfactory documentation of the medical necessity for this modality of wound 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 NPWT pump have been met. Therefore, we decided that the Plan has to pre-approve a negative pressure wound therapy (NPWT) pump.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), an unspecified preventive procedure (D1999 x2), pulp vitality tests (D0460), an apicoectomy - anterior (D3410), a retrograde filling (D3430), and inhalation of nitrous oxide (D9230) provided from January 6, 2021, through January 14, 2021.
You asked the Plan to pay an additional amount for a limited oral evaluation, an intraoral periapical radiographic image, an unspecified preventive procedure, pulp vitality tests, an apicoectomy - anterior, a retrograde filling, and inhalation of nitrous oxide. You say that the services were not preventive procedures. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made. An unspecified preventive procedure, pulp vitality tests, an apicoectomy - anterior, a retrograde filling, and inhalation of nitrous oxide are not covered benefits.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, an intraoral periapical radiographic image, an unspecified preventive procedure, pulp vitality tests, an apicoectomy - anterior, a retrograde filling, and inhalation of nitrous oxide have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Additionally, an unspecified preventive procedure, pulp vitality tests, an apicoectomy - anterior, a retrograde filling, and inhalation of nitrous oxide are not covered benefits. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), an unspecified preventive procedure (D1999 x2), pulp vitality tests (D0460), an apicoectomy - anterior (D3410), a retrograde filling (D3430), and inhalation of nitrous oxide (D9230) provided from January 6, 2021, through January 14, 2021.