Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam (D2150), the resin based composite for an anterior tooth (D2330), and resin based composites for a posterior tooth (D2391 x 2) provided on October 26, 2020.
You asked the Plan to pay for the dental services. You say that the fillings and x-rays should be covered. You say that you are enrolled in the best Advantage Plan. You also say that amalgams and composites are mentioned but there is no refusal for x-rays. The Plan denied your request. The Plan says amalgam is not listed as a covered service. The Plan says resin based composites are not listed as covered service either.
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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the amalgam (D2150), the resin based composite for an anterior tooth (D2330), and resin based composites for a posterior tooth (D2391 x 2) provided on October 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PRALUENT.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve PRALUENT.
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from October 26, 2020, to
November 11, 2020.
You asked the Plan to pay for the dental services. You say that you were advised that Medicare would cover
these services. You also say that the enrollee is on a fixed income. The Plan denied your request. The Plan says
the enrollee's calendar year maximum had 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, the Plan offers a $1,000 combined
allowance for supplemental preventive and comprehensive services every year. You are responsible for any
amount over and above the allowance amount. The record shows that you met the annual maximum benefit on
October 26, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for the dental services provided from October 26, 2020, to November 11, 2020.
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 are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 the enrollee does not require the intensity of service provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as sub-acute rehabilitation or skilled nursing facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ultraviolet (UV) and scratch resistant coating lens upgrades for eyeglasses provided on January 10, 2020.
You asked the Plan to pay for eyewear upgrades. You say that these were basic glasses with no special features. The Plan denied your request. The Plan says the denial of payment for these items is correct, because these routine eyewear upgrades are not covered by the Plan.
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 does not cover UV or scratch resistant coating lens upgrades. We looked at the file and the Plan's rules. These eyewear upgrades are not covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of eyewear upgrades have not been met. Therefore, we decided that the Plan does not have to pay for ultraviolet (UV) and scratch resistant coating lens upgrades for eyeglasses provided on January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc (J7327).
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the records do not show that the enrollee has had a poor response to one of the other drugs (Euflexxa, Supartz Fx, Durolane, or Gelsyn-3) first.
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 Monovisc. Our reviewer says that Monovisc is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Euflexxa, Supartz Fx, Durolane, or Gelsyn-3 before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc (J7327).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgent needs this device due to her worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because CardioMEMS is experimental/investigational.
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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found data obtained from a CardioMEMS device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and it is not recommended in current guidelines for the treatment of heart failure. This device should still be considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vagus nerve stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says there are no partial onset seizures or treatment-resistant depression.
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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested stimulator is not reasonable or necessary for treatment of bipolar disorder (current episode, depressed, moderate). Based on the information provided use of vagal nerve stimulation is not considered reasonable and medically necessary based on the stance by CMS for the treatment of this disorder. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a vagus nerve stimulator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
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 based on the documentation provided, the health plan's denial of LTACH coverage
should be upheld. You are currently undergoing treatment at an acute care hospital (ACH) for CoViD-19 in the
setting of pulmonary fibrosis and cirrhosis. You were intubated/ventilated and subsequently received a
tracheotomy. You remain on a ventilator and do not appear to be currently weanable. There is no evidence that
you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same
level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current
ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of
care for any ongoing long-term care needs.
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-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiology visits provided on October 24, 2020 and October 25, 2020.
You asked the Plan to waive the copayments for cardiology visits. You say that the enrollee was an inpatient on these dates and when admitted as an inpatient, billed charges are together. The Plan denied your request. The Plan says the copayment amounts the enrollee is being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $35 copayment for each specialist visit. The record shows that the enrollee's patient status on these dates of service was outpatient observation, therefore separate cost-sharing applies to these cardiology visits. For the visit on October 24, 2020, the enrollee has been asked to pay $35 copayment. For the visit on October 25, 2020, the enrollee has been asked to pay the allowed amount of $27.37 because this is less than the $35 copayment amount. Therefore, the enrollee's total copayment obligation is $62.37. The enrollee has been asked to pay $35 copayment or less for each cardiology visit. Cardiology visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for cardiology visits provided on October 24, 2020 and October 25, 2020.
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 these services. You say that you have an ankle problem and need support
inserts. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided from May 9, 2020, to May 13, 2020.
You asked the Plan to pay for self-administered drugs. You say that you should not have to pay for these drugs that you did not ask for. The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because these drugs are not covered by Medicare Part B and coverage should be requested under your Medicare Part D prescription drug benefits.
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 pay for self-administered drugs provided from May 9, 2020, to May 13, 2020.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says because the enrollee
not using this drug for a medically-accepted indication, it is not covered under their medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that Evenity
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the use of Evenity is
food and drug administration (FDA) approved for osteoporosis. The enrollee has gastroesophageal reflux
disease (GERD) and cannot take bisphosphonates. Our reviewer found that the enrollee has been on FORTEO
injections for two years. There is no medical literature to support the use of Evenity therapy in patients who
have been on FORTEO injections for two years. Our physician reviewer also found that Evenity therapy is
experimental in this case and not supported by current medical literature because the enrollee has already been
on FORTEO for two years.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment purchased on September 24, 2020 from an out of network (OON) provider.
You asked the Plan to pay for oxygen equipment. You say that you are requesting reimbursement for this item. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is out-of-network with the Plan and approval was not obtained for this provider. The Plan says that they approved oxygen equipment from an in-network provider, but not from the requested out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for oxygen equipment purchased on September 24, 2020 from an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397).
You asked the Plan to pay for the knee orthosis and the suspension sleeve. You say that the services provided were medically necessary. The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that for the requested orthosis, knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 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 knee orthosis and the suspension sleeve. Our reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and the suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs sensor (C2624).
You asked the Plan to pre-approve a CardioMEMs sensor. You say that the enrollee urgently needs this device to manage fluid status. The Plan denied your request. The Plan says the requested device is considered experimental.
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 a CardioMEMs sensor. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMs device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMs sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs sensor (C2624).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. You have made progress with therapy, but your functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.