Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a need for skilled nursing services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. There is no recent documentation to support that you would require 
skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your 
condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You were 
making small gains in strength with occupational therapy in June 2020 but there is not any recent medical 
records to support a significant improvement in function.  The skilled care 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code E1399. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the 
compression stockigns because they have varicose veins. The Plan denied your request. The Plan says gradient 
compression stockings are a covered benefit when it is used in treatement of an open venous stasis ulcer which 
the enrollee does not have. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 
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 the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does 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-approve compression stockings 
identified with code E1399.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the requested oral sleep apnea appliance.
You asked the Plan to pay for the oral sleep apnea appliance. The Plan denied your request. The Plan says the
enrollee must receive care from in-network providers with the exception of emergency or urgent care or if the
care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 the requested oral sleep apnea appliance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure nutritional supplement.
You asked the Plan to pre-approve Ensure nutritional supplement. You say that you are appealing the denial of
the Ensure. The records should support the necessity of the requested item. The Plan denied your request. The
Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan
does not have to pre-approve Ensure nutritional supplement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the new wheelchair is medically 
necessary. The Plan denied your request. The Plan says a wheelchair was provided in 2017. It has not reached 
its useful life. A new wheelchair cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in no case can the reasonable useful lifetime of 
Durable Medical Equipment (DME) be less than 5 years.  
 
We looked at the file and Medicare rules. A manual wheelchair was already provided in November, 2017. The 
chair provided has not reached its reasonable useful lifetime and therefore a new chair cannot be covered.  
Based on this information, we decided that Medicare rules for coverage of the manual wheelchair have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an independent caretaker (99509).
You asked the Plan to pre-approve the caretaker. You say that you would like reconsideration because you need assistance with cooking and transportation. The Plan denied your request. The Plan says homemaker services are not covered under any condition.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the caretaker have not been met. Specifically, you are requesting homemaker services. Homemaker services are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve an independent caretaker (99509).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance. 
 
You asked the Plan to pre-approve periodontal maintenance. You say that you require additional cleanings per 
year and you would like to use your $200 allowance towards the cleanings. The Plan denied your request. The 
Plan says the requested service is not covered under the plan 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 pre-approve 
periodontal maintenance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you have already established care with this 
provider. The Plan denied your request. The Plan says there are in-network tertiary care neurologists that can 
provide these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
neurology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture and a complete maxillary 
denture. 
 
You asked the Plan to pre-approve the mandibular partial denture and complete maxillary denture. The Plan 
denied your request. The Plan says these services are only covered 1 time in a 60 month time period. The Plan 
also says that you have already received these services within that time period. 
 
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 limited to 1 every 5 years. 
The record shows that you received a mandibular partial denture on July 16, 2015, and a complete maxillary 
denture on January 11, 2017, and your dentures benefit had been exhausted at the time of your request. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture and a complete 
maxillary denture.  
 
Please Note: At the time your request was made, your both your mandibular and maxillary dentures benefits 
were exhausted. However, your last mandibular partial denture was received on July 16, 2015, and you were 
eligible for this benefit as of July 16, 2020. Since it is past the 5 year time period, you are able to make a new 
request for the mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joint injection. 
 
You asked the Plan to pre-approve the requested services. You say that physical therapy sessions were not 
effective. The Plan denied your request. The Plan says the procedure is not part of the current active treatment 
plan. 
 
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 documentation in the case file shows that the requested injection 
is not part of your current treatment. The information from your provider shows that the injection was 
requested in error. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories (wedge cushions, balance lift, center mount calf pads, privacy flap, logic joystick, foot plate extension) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the power wheelchair and some of the accessories can be approved.
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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E0995 is not medically necessary as this was already included in the allowance of the power wheelchair and is not a replacement item. Additionally, the K0108 foot plate extension components are also already included in the leg rest components that were authorized. The K0108 privacy flap and the K0108 logic joystick are both not medically necessary as these items are not reasonable and necessary for the enrollee's illness/injury or needed to improve a malformed body member. The K0108 lateral positioning wedge is already included in the tru comfort back which was approved and therefore not medically necessary for the enrollee's illness or to improve a malformed body member. The request for a E2300 lift is not primarily medical in nature and therefore 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessories (wedge cushions, balance lift, center mount calf pads, privacy flap, logic joystick, foot plate extension) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four endosteal implants (D6010 x4). 
 
You asked the Plan to pre-approve the endosteal implants. You say that the dental implants are medically 
necessary for the enrollee's mastication. The Plan denied your request. The Plan says this service is not a 
covered benefit under the enrollee's benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
endosteal implants (D6010 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair accessory, cushion cover.
You asked the Plan to pre-approve the wheelchair accessory. You say that the enrollee does not reside in a skilled nursing facility. She lives in the assisted living section of the facility and remains medically necessary and appropriate for the wheelchair being requested The Plan denied your request. The Plan says this is a convenience item and does not primarily serve a medical purpose.
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. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair accessory, cushion cover.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic x-ray (D0330).
You asked the Plan to pay for the panoramic x-ray. You say that you have this type of x-ray performed every five years. You also say that this x-ray is medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefit 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 a panoramic x-ray (D0330).
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 you have been having foot pain for two years and the treatment you have been receiving has not alleviated the pain. You say that when you previously had foot pain, orthotics were prescribed for you and the issue was quickly resolved. You stated that you are a physically active person and you would like to stay that way, however your foot pain has limited your levels of activity. You say that you would like the Plan to reconsider their denial because of the level of pain you are experiencing and the resulting limitations in your physical activity that could result in other medical conditions. 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: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve healthy food deliveries.
You asked the Plan to pre-approve the healthy food deliveries. You say that you would like reconsideration because you are eligible for this benefit. The Plan denied your request. The Plan says that the records do not show that you were recently discharged from an overnight hospital stay.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. In this case, the Plan provides supplemental benefits for delivery service so the Plan rules apply. We looked at the file and rules. Based on this information, we decided that Plan's rules for coverage of the healthy food deliveries have been met. Specifically, the record indicates that you have a BMI of more than 25. Therefore, we decided that the Plan has to pre-approve healthy food deliveries.
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The plan must follow Medicare rules. The rules say that anatomical 
modifiers are required for procedures performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The services at issue are laboratory tests billed with the -T1 modifier. 
This anatomical modifier is not appropriate for these codes. Therefore, we decided that the Plan does not have 
to pay for the laboratory services rendered on January 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre approve the additional non-emergency routine transportation. 
 
You asked the Plan to pre approve the additional transportation. You say that you need dialysis 3 times week 
and you have no other means of going and you need transportation to get to your appointments. The Plan 
denied your request. The Plan says this request exceeds the benefit frequency limitation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 30 one way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre approve the additional non-emergency routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle diabetic test strips.
You asked the Plan to pre-approve the freestyle test strips. You say that the test strips are medically necessary. The Plan denied your request. The Plan says only the Accu-Chek line of products are covered.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. The requested Freestyle test strips are not a covered brand. The record shows no reason why the enrollee cannot use the plan preferred Accu-Chek product line. Based on this information, we decided that Medicare rules for coverage of the freestyle test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle diabetic test strips.