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

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 pre-approve Prolia.
Benefits for Prolia 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 haveto pre-approveAnoro Ellipta 62.5-25mcg inhaler.You asked the Planto pre-approvethe Anoro Ellipta inhaler. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication is self-administered anddoes not meet criteria for coverage under Part B.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-approveAnoro Ellipta 62.5-25mcg inhaler.Benefits for the Anoro Ellipta inhalermay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery to repair a fistula. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at thisphysician'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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthoses (L1971x2) provided on October 9, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided support the necessity of the
services in dispute. The Plan denied your request. The Plan says this item was previously provided on
December 21, 2018 and there is insufficient documentation to corroborate the service so that the Medicare
coverage criteria has been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. Medicare rules say that for eligible telehealth services, telecommunications systems
substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are
presented from an authorized originating site located in either a county outside of a Metropolitan Statistical
Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for ankle foot orthoses
(L1971x2) provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple tooth extractions.
You asked the Plan to pre-approve the extractions. You say that the enrollee needs an aortic valve replacement
but due to the risk of infection from poor dentition, the enrollee needs eleven teeth extracted first. You also say
that the enrollee is fearful of having her teeth extracted under local sedation. The Plan denied your request. The
Plan says dental procedures and the removal of teeth are benefit exclusions.
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
multiple tooth extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe power wheelchair seat elevation system and upgraded electronics.You asked the Plan to pre-approvethe power wheelchair seat elevation system (E2300), and the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the power seat elevation feature and expandable control system.The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare andthe upgraded electronics are not necessary.The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.  The power seat elevation featureat 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.The expandable control system is not necessary as there is only two approved power seating features. Therefore, we decided that the Plan does not have to pre-approvethe power wheelchair seat elevation system and upgraded electronics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on September 3, 2019.

You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that nowhere in the 2019 Annual Notice of Changes does it state that you can only use in-network dental care providers. You also say that you spoke with a Plan representative and they never informed you that you could only use in-network dental care providers. The Plan denied your request. The Plan says these services are denied because the services were received by an out-of-network provider. The Plan also says that they confirmed that you were advised that your benefits were only available when received from an in-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on September 3, 2019.
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 preapprovea pneumatic compression device (E0652)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pre-approve pneumatic compression device (E0651) and garments (E0667x2)You asked the Plan to pre-approve pneumatic compression device and garments. You say that you believe the medical records supports the coverage criteria listed.The Plan denied your request. The Plan says that the enrollee does not meet the medical necessity for coverage of the pneumatic compression device.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 pre-approve pneumatic compression device and garments. 
Our reviewer says that this enrollee has met the coverage criteria for a pneumatic leg compression device, for the treatment of chronic lymphedema. Our physician reviewer found the medical records document the persistent presence of severe lymphedema, with the failure of conservative measures to give relief over a period of several months. The pneumatic leg compression device is considered reasonable and medically necessary for this 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 pneumatic compression device and garments have been met.Therefore, we decided that the Plan has to pre-approvepneumatic compression device (E0651) and garments (E0667x2)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-rays provided on September 9, 2019.You asked the Plan to pay for the additional x-rays. You say that these services should be paid by the Planbecause you have not been to a dentist since 1998 and needed these services.The Plan denied your request. The Plan says these services exceed the maximum allowed per 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, dental x-ray(s) are limited to 1 a year. The record shows that you received a first intraoral periapical x-ray on September 9, 2019 and your dental x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-rays provided on September 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on September 9, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that you do not agree with the decision as the service was needed. You are appealing the claim payment denial for services rendered to the Plan's member on date of service September 9, 2019. The Plan denied your request. The Plan says this provider is a non-participating provider. The attending provider is also a non-participating provider. You did not authorize any services for this practice or these providers. The services are not considered urgent/emergent in nature.
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 an office visit (99214) provided on September 9, 2019 by the out of network provider.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules.The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee is with history of diabetes, atherosclerotic cardiovascular disease, atrial fibrillation, hypertension and metastatic prostate cancer who was admitted to the acute hospital on 1/21/2020 after a motor vehicle crash. He sustained a non-displaced C2 fracture that has been treated non-operatively with a cervical collar. He is walking 125 feet with a rolling walker, requiring supervision, set up or contact guard assist with activities of daily living. He has 4/5 strength in both upper and lower extremities. His range of motion in his lower extremities is full; reduced in upper extremities. Medical conditions are stable. Cardiac evaluation in hospital negative for any acute issue -ejection fraction 40-45%.Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there does not appear to be a need for an intensive rehabilitation therapy program as provided in an inpatient rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on September 5, 2019.You asked the Plan to pay forthe dental service. You say that you were not told about the $500 maximum until after you received the work that was approved.The Plan denied your request. The Plan says the annual maximum has been exceeded. The Plan also says that you are responsible for any amount over the maximum.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 annual maximum has been reached. The record shows that the Plan paid $226 towards the services received on July 15, 2019, $87 towards the services received on June 10, 2019, and $187 towards the services you received on July 29, 2019. among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology (88305), an ultrasound (76872) and a biopsy of the prostrate (55700) provided on September 23, 2019 by out of network provider.
You asked the Plan to pay for surgical pathology, an ultrasound and a biopsy of the prostrate. You say that as demonstrated by the documentation, the service provided was clinically appropriate and medically necessary. The Plan denied your request. The Plan says the attending provider is a non-participating provider. We did not authorize any services for the OON provider or the OON doctor. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 surgical pathology (88305), an ultrasound (76872) and a biopsy of the prostrate (55700) provided on September 23, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, provided on May 20, 2019.
You asked the Plan to pay for the core buildup. You say that you told the dentist that you were not covered for dental benefits and had to purchase insurance first. You also say that the dentist rendered the service anyway. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.
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 core buildup, including any pins when required, provided on May 20, 2019.
Your complaint about the provider rendering the service after you told him you needed to purchase insurance first 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on September 27, 2019.You asked the Plan to waive the copayment for the MRI. You say that you were informed you would only have a $15 copayment. You say that you cannot afford this bill.The Plan denied your request. The Plan says the copayment applied 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 $225 copayment for diagnostic imaging (CT scans, MRIs, MRAs, PET scans, sleep studies, nuclear cardiology).You have been asked to pay a $225 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe MRI provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
August 15, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis
(L3916) provided to the enrollee on August 15, 2019.