Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. You asked the Plan to pre-approve a power scooter. You say that that a scooter is a necessity for you. The Plan denied your request. The Plan says that your provider has not submitted any medical records for review. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your provider has not submitted any medical records in this case. Without this documentation it cannot be determined if you have a mobility deficit that impairs your participation in MRADLs, that your condition cannot be improved by a walker, cane or manual wheelchair or you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need the requested shower chair because you cannot stand by yourself in order to take a shower. You say that you are currently unable to shower on your own and you asked the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve basic above ground swimming pool (E1399). You asked the Plan to pre-approve the swimming pool. You say that you were receiving physical therapy (PT) at a facility with a pool but do to COVID 19 the facility has closed. You would like an above ground swimming pool to resume PT water therapy.The Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve basic above ground swimming pool (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transportation trip for a total of 82.8 miles.
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 request exceeds the benefit limit.
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 routine transportation for up to 24 one-way trips and each trip must not exceed 50 miles
from the pickup location.
We looked at your request, the records in the case file, and the rules. The file shows that the requested one-way
trips is for a total of 82.9 miles. Based on this information, we decided that the Plan's rules for coverage of
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a
routine transportation trip for a total of 82.8 miles.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.
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 Durolane. Our reviewer says that criteria is not met for this drug. Our physician reviewer found the provided medical records do indicate that the enrollee has tried and failed Monovisc but there is no indication that Orthovisc has been tried and failed. The provided medical records do not indicate that Orthovisc 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visual field assessment, with concurrent real time data.
You asked the Plan to pre-approve visual field assessment, with concurrent real time data (0379T). You say
that this procedure is covered by Medicare. The Plan denied your request. The Plan says this procedure is
considered experimental and investigational.
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. Visual field assessment, with concurrent real time data (0379T) is not
a covered procedure. Therefore, we decided that the Plan does not have to pre-approve visual field assessment,
with concurrent real time data.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the automatic blood pressure monitor (A4670).You asked the Plan to pre-approve the automatic blood pressure monitor. You say that your doctor does your regular check but do to the pandemic you were advised to check your blood pressure daily at home. Since COVID 19 erupted, you have not checked your blood pressure yourself.The Plan denied your request. The Plan says this request is not a covered benefit. Home blood pressure cuffs are only covered for patients who are on home dialysis.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 the automatic blood pressure monitor (A4670).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedestruction of cervical thoracic facet joint injections (64633, 64634).You asked the Plan to pre-approvedestruction of cervical thoracic facet joint injections. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonableand necessary when specific criteria is 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 destruction of cervical thoracic facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the coverage criteria is very specific as to the requirement for 2 separate sets of diagnostic MBBs that produce greater than 80% pain relief. This has not been done. Therefore, the request is deemed not medically reasonable or necessary at this point.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction of cervical thoracic facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvedestruction of cervical thoracic facet joint injections (64633, 64634).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous DME supply, accessory, and/or service component of another HCPCS code (A9900) and power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
You asked the Plan to pre-approve the DME). You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. There is no documentation indicating that you have any difficulty performing activities of daily living (ADL) in your home. Therefore, we decided that the Plan does not have to pre-approve miscellaneous DME supply, accessory, and/or service component of another HCPCS code (A9900) and power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the aquabeam transurethral waterjet ablation of prostate
You asked the Plan to pre-approve the aquabeam transurethral waterjet ablation of prostate. You say that you believe aquablation therapy is the best treatment for the enrollee because less invasive alternatives are no longer appropriate. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan. Medical studies have not proven that this procedure is helpful for treatment of your health problem.
The Plan must follow Medicare rules. Medicare rules 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 aquabeam transurethral waterjet ablation of prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve the aquabeam transurethral waterjet ablation of prostate
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture.
You asked the Plan to pre-approve a complete lower denture. The Plan denied your request. The Plan says that this is 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, 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 a complete lower denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have a fractured hip along with other
medical issues. You say that you have had several falls and are at a high risk for more. You stated that you
need the requested shower chair to provide stability and safety when you are able to get into the bathroom. You
say that currently you are spending a lot of money for nurse assistance and you are hoping that the requested
shower chair will help you become independent sooner. The Plan denied your request. The Plan says this item
is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep gum and root cleaning, LRQ, LLQ, ULQ, URQ (D4341x4). You asked the Plan to pre-approve the dental service. You say that you did not receive this service on July 29, 2019 and request reconsideration of the denial for coverage.The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.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. This service is allowed once every 24 months. Records show that this service was provided on July 29, 2019.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 deep gum and root cleaning, LRQ, LLQ, ULQ, URQ (D4341x4).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for puncture aspiration provided on March 17, 2020.
You asked the Plan to waive the copayment for puncture aspiration. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $600 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $523, which is less than the $600 copayment for puncture aspiration. Puncture aspiration falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 puncture aspiration provided on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation system (E0483) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the high frequency chest wall oscillation system. You say that you would like the system provided by the out-of-network provider because you have used it already and it works for you.The Plan denied your request. The Plan says there are network providers that can provide a comparable item.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 the high frequency chest wall oscillation system (E0483) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurological surgery for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says it is unclear how this procedure would improve the pain.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it cannot be said that the use of a spinal cord stimulator would be used for a condition consistent for which the guidelines support the use of a stimulator. In all of the records, there is no mention of any prior lumbar surgery. There is no adequate documentation of any form of neurosurgical evaluation that indicated that the enrollee was not a surgical candidate.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve neurological surgery for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional logisticare mileage. You asked the Plan to pre-approve additional logisticare mileage. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met. 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 36 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. 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 additional logisticare mileage.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 to February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for portable X-Ray services. You say that your services are treated as emergency care and it is next to impossible to obtain authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 7, 2020 to February 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 31, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area 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 physician's services provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an intermittent limb compression device (E0652).You asked the Plan to provide an intermittent limb compression device (E0652). You say that you would like an exception for this device.The Plan denied your request. The Plan says the enrollee does not have upper extremity edema, therefore this request does not meet Medicare guidelines.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 provide an intermittent limb compression device (E0652). Our reviewer says that criteria is not met for the pneumatic compression device. Our physician reviewer found there is no evidence of at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 PCD after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.The enrollee also must have lymphedema of an extremity therefore,this device would not be appropriate for the head and neck.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intermittent limb compression device (E0652) have not been met.Therefore, we decided that the Plan does not have to provide an intermittent limb compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 14, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area 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 nurse practitioner services provided on August 14, 2019.