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

We decided that the Plandoes not haveto pre-approveViberzi for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysself-administered drugs are not covered.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 Plandoes not haveto pre-approveViberzi for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approveseptoplasty with inferior turbinate resection.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis type of surgery is not indicated for snoring.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found nasal obstruction contributes to increased airway resistance. Nasal obstruction may contribute to open-mouth breathing during sleep, which can increase the collapsibility of the upper airway. Snoring can be caused by nasal obstruction. Surgical procedures that aim towards improving nasal breathing have demonstrated improvement in snoring following the surgery. Therefore, nasal obstruction secondary to bony or cartilaginous deformation should be treated. Improving nasal patency can help restore physiologic breathing.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 been met.Therefore, we decided that the Planhas to pre-approveseptoplasty with inferior turbinate resection.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the out of network referral. You say that you would like reconsideration as this provider replaced your voice prosthesis when needed in the past. The Plan denied your request. The Plan says there are participating facilities available in-network who are able to treat your condition.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 withthe 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include neurologic monitoring, intravenous antifungal medicaitons, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs orthotics to help relieve back, leg, and hip pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from November 8, 2018 to December 7, 2018.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says no skilled rehabilitation services were provided during this time frame because assessment showed the enrollee to be at her functional baseline.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing servicesprovided from November 8, 2018 to December 7, 2018
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe acute inpatient level of care for spinal surgery.You asked the Plan to pre-approveacute inpatient hospital care. You say that the services are medically necessary.The Plan denied your request. The Plan says the surgery is approved but the inpatient level of care is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the inpatient level of care is not medically necessary. Our physician reviewer found the enrollee is planned for a lumbar spinal decompression. The records do not document any comorbidities that would justify an inpatient admission. The surgery can be performed at the outpatient level of care. The records do not support a reasonable expectation that the enrollee will require at least two midnights of inpatient care for the planned surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe acute inpatient level of care for spinal surgery
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX (Hyaluronate).You asked the Plan to pre-approveSupartz FX. You say that the enrollee needs this to avoid a knee replacement.The Plan denied your request. The Plan says he enrollee has not tried Monovisc and Orthovisc as required by step therapy rules.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 Supartz FX. Our reviewer says that the criteria for coverage of Supartz FX have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried Monovisc and Orthovisc or that these drugs would likely be less effective or have adverse effects for the enrollee 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 Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX (Hyaluronate).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cementing of a crown (D2920) provided on October 7, 2019.
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says the re-cementing of a crown 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 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 re-cementing of a crown (D2920) provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to cover 50% of the porcelain retainer crowns on tooth #'s 13 and 14 provided on September 4, 2019.
You asked the Plan to cover 50% of the retainer crowns on tooth #'s 13 and 14. You say that you were not told about the $1,000 annual maximum benefit cap on your coverage. You say that you were told by the Plan that you would be responsible for 50% of the work with a $100 deductible. The Plan denied your request. The Plan says your annual maximum benefit had been exhausted.
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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on September 4, 2019 and your annual deductible benefit has been exhausted. The Plan is only obligated to pay up to the $1,000 annual maximum, and any charges over this amount are your responsibility. Therefore, we decided that the Plan does not have to cover 50% of the porcelain retainer crowns on tooth #'s 13 and 14 provided on September 4, 2019.
Your complaint about not being given all of the information regarding your dental benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on May 14, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says there is no documentation of back pain, treatment or need for bracing.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The enrollee was not seen in office on the day of order and the medical records do not support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on August 7, 2019.
You asked the Plan to pay for the hearing aids. You say that it is very confusing to offer out of network coverage for hearing aids, but then restrict the vendor network. The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not ordered through the designated vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only the plan only covers hearing aids when purchased through specific providers. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProdigy brand diabetic test strips.You asked the Planto pre-approvethe Prodigy brand test strips. You say that the enrollee needs test strips and Prodigy is the brand she uses.The Plandenied your request. The Plansaysa 90-day supply of the non-preferred brand has been approved since the enrollee is new to the plan. However, there is no indication that this specific brand is medically necessary. After the 90 day trial, the enrollee will have to transition to a preferred brand of monitor and test strips.The Plan must follow Medicare rules. Medicare rules say that plans may restrict coverage of certain equipment to specific brands as long as all medically necessary items are available if needed. In this case, there is no evidence that there is a medical reason for the request for Prodigy brand test strips. There is no documentation showing that one of the preferred brands is medically inappropriate.Therefore, we decided that the Plandoes not haveto pre-approveProdigy brand diabetic test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe resin based composite, 3 surfaces, for an anterior tooth (D2332) provided on October 29, 2019.You asked the Plan to pay the in network rate forthe dental service. You say that you had 2 terrible experiences at in network dentists. You also say that you went out of network because of this.The Plan denied your request. The Plan says services that are not received from a participating general dentist are not covered. The Plan also says that the dentist in this case is not a participating dentist.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, services received out of network are not covered.Therefore, we decided that the Plan does not have to pay the in network rate forthe resin based composite, 3 surfaces, for an anterior tooth (D2332) provided on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride and resin-based composite on tooth #30 provided on October 15, 2019.
You asked the Plan to pay for the topical application of fluoride and resin-based composite. The Plan denied your request. The Plan says the number of times that you can have these services has been reached.
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, fluoride treatment is limited to once every 12 months. The contract also says that resin-based composites are limited to once every 36 months. The record shows that you received a fluoride treatment on April 3, 2019 and a filling on tooth #30 on August 10, 2017 and your fluoride treatment and resin-based composite benefits were then exhausted. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride and resin-based composite on tooth #30 provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Libre Continuous Glucose Monitor (CGM) sensors. You asked the Plan to pre-approve Freestyle Libre Continuous Glucose Monitor (CGM) sensors. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Medicare says that therapeutic CGMs and related supplies are covered when all of the above criteria (1-6) are met. In this case, the file shows that the enrollee is not insulin-treated with at least three or more daily injections and does not have a Medicare-covered CSII pump. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre Continuous Glucose Monitor (CGM) sensors have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre Continuous Glucose Monitor (CGM) sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea gradient sleeve and gradient pressure aid gauntlet identified with codes S8424, S8428.You asked the Plan to pre-approvea gradient sleeve andgradient pressure aid gauntlet. You say that you need a gradient sleeve andgradient pressure aid gauntlet to control pain and swelling from a medical condition. The Plan denied your request. The Plan says a gradient compression wrap is only covered when used as a dressing over wounds.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code S8424, S8428 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvea gradient sleeve and gradient pressure aid gauntlet identified with codes S8424, S8428
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) and a complete maxillary denture (D5110).You asked the Plan to pre-approvethe dental services. You say that you need dentures so that you can eat properly.The Plan denied your request.The Plan says dentures are not 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, dentures are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea complete mandibular denture (D5120) and a complete maxillary denture (D5110).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 26, 2019 and July 27, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that the copayments are outrageous. The Plan denied your request. The Plan says you were charged this cost sharing 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 $200 copayment for each ambulance trip. You had two ambulance trips. The Plan charged you $400 for these services. 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 ambulance services provided on July 26, 2019 and July 27, 2019.