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

We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out-of-network provider.You asked the Plan to pre-approve an oral appliance from an out-of-network provider. You say that you were denied authorization to see an in-network provider. The Plan denied your request. The Plan says your plan does not provide out-of-network benefits.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. The Plan has confirmed there was no request and denial of authorization to see the in-network provider. 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 an oral appliance to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta. 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 services are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis and received a Zilretta injection in 2018. The Medicare compedia do not support repeat injections of Zilretta as safe and effective for the enrollee's condition; therefore, the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Entresto tablets.
You asked the Plan to pre-approve the Entresto tablets.. You say that this medication would benefit the enrollee
better in managing her heart disease. The Plan denied your request. The Plan says Entresto is not a covered
benefit under the enrollee's plan because this is a drug that is taken orally.
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 the Entresto tablets.
Benefits for Entresto tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a naturopath.You asked the Plan to pre-approve these services. You say that the enrollee has chronic sinus and urinary tract infections.The Plan denied your request. The Plan says the services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. These services are not covered by Medicare under any condition.Therefore, we decided that the Plan does not have to pre-approve a referral to a naturopath.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee tested positive for COVID-19 and needs to move to a SNF and out of a residential level of care. The Plan denied your request. The Plan says the criteria for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs and was alert with confusion. The enrollee had uncomplicated wound care to her coccyx and received oral antibiotics. The enrollee had a cough, but no respiratory distress. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 7, 2020.You asked the Plan to pay for the dental service. You say that you had an issue with a crown. You say that the dental provider performed an x-ray to review the issue.The Plan denied your request. The Plan says the frequency limit for dental x-rays has been exceeded.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 and x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for bitewing x-rays that you received less than 1 year prior on April 23, 2019.Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership reimbursement for 2018.

You asked the Plan to pay for the gym membership. You say that the plan has regularly approved request in prior years. Your membership spans two years so you are entitled to reimbursement in the amount of $150 for both years  of 2019 and 2020. The Plan denied your request. The Plan says the claim for 2018 wellness reimbursement was not submitted within the required time frame.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only Reimbursement requests must be received no later than March 31st of the following year.

The Plan's rules for coverage of gym benefits have not been met because the claim for 2018 wellness reimbursement was not submitted within the required time frame. Therefore, we decided that the Plan does not have to pay for the gym membership reimbursement for 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a leadless pacemaker You asked the Plan to pre-approve a leadless pacemaker. The Plan denied your request. The Plan says that leadless pacemakers are only covered under CED when part of a CMS approved FDA study or an associated post-approval study.The Plan must follow Medicare rules. Medicare rules say that leadless pacemaker devices are only covered in a Medicare-approved clinical study. Leadless pacemakers are non-covered outside of an approved study.We looked at the file and Medicare rules. The requested leadless pacemaker procedure is not covered by Medicare outside of an approved clinical study. The file does not indicate the enrollee is enrolled in an approved study. Based on this information, we decided that Medicare rules for coverage of a leadless pacemaker have not been met.Therefore, we decided that the Plan does not have to pre-approve implantation of a leadless pacemaker
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara under your Part B benefit.You asked the Plan to pre-approve Stelara under your Part B benefit. You say that you want this drug to be covered under your Part B benefit.The Plan denied your request. The Plan says they will cover the maintenance therapy under your Part D 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-approveStelara under your Part B benefit.Benefits for Stelara under your Part B benefit 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is noted to have been admitted following a bout of sepsis from a urinary source. The enrollee was managed medically, and is now afebrile and hemodynamically stable. O2 saturation levels are acceptable. The enrollee is still very much debilitated and required maximum assist for transfers and activities of daily living. The documentation does not support that the enrollee requires treatment by or would be able to fully benefit from and/or participate in an IRF level of care. The documentation does not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a  lower level of care.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a Coflex interspinous spacer. You asked the Plan to pre-approve the Coflex device. You say that this should be covered as a proven treatment for this enrollee's condition. The Plan denied your request. The Plan says this is not proven to be as effective as standard treatments. 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 Coflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 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 Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a Coflex interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and additional intraoral periapical x-ray provided on January 16, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray and additional intraoral periapical x-ray. You say that you feel that you are being discriminated against because of your upper denture. You also say that your dentist uses a different x-ray.The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. The contract says that only bitewing x-rays are covered.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and additional intraoral periapical x-ray provided on January 16, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eszopiclone 2mg tablet for the enrollee.
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your request. The Plan says oral medications are considered self-administered drugs.
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 Eszopiclone 2mg tablet for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea PET scan.You asked the Plan to pre-approvea PET scan. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the requested PET scan is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the documentation does not support that the requested PET scan is medically reasonable or necessary. Our physician reviewer found the enrollee has hormone sensitive metastatic prostate cancer. The documentation shows that CT scans showing adenoapthy. The enrollee has just started treatment with LHRHagonist/antagonist. There is no suspected recurrence. Therefore, the enrollee does not meet criteria for the requested PET scan.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 PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea PET scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 genetic testing services.
You asked the Plan to pre-approve the F2 genetic testing. You say that the requested testing is medically necessary. The Plan denied your request. The Plan says the test being requested is not considered to be clinically efficacious and is not medically necessary.
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. Medicare rules say that F2 genetic tests are not clinically efficacious and not are not considered medically necessary. Therefore, we decided that the Plan does not have to pre-approve F2 genetic testing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided by a participating provider on November 11, 2019 to November 18, 2019. You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $395 per day for days 1 through 4 of each inpatient hospital admission. You have been asked to pay a $1,580 copayment for 4 days of an inpatient hospital admission. 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 inpatient hospital services provided by a participating provider on November 11, 2019 to November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise equipment (A9300).
You asked the Plan to pre-approve exercise equipment. You say that due to the Covid 19 crisis you cannot go to the gym and needs to have the exercise machine to make movement in your legs and arms to prevent blood clots. The Plan denied your request. The Plan says this item is not covered.
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 exercise equipment (A9300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV). You asked the Plan to pre-approve the Group 2 POV. You say that this is medically necessary to help with mobility.The Plan denied your request. The Plan says this type of scooter is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs are not necessary for use in the home and are not covered.Although this POV may be appropriate, it is not considered reasonable and necessary for Medicare coverage.Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0676).You asked the Plan to pre-approvea pneumatic compression device. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says this service is not covered.The Plan follows Medicare rules. Therules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rulesfor coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal scalings (D4341 x4) provided on December 13, 2019 and December 17, 2019.You asked the Plan to pay forthe periodontal screenings (D4341 x4). You say that you were told the periodontal scalings would be covered in 2019. The Plan denied your request. The Plan says the services are not covered 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 periodontal screenings (D4341 x4) are not among those covered under this benefit. Therefore, we decided that the Plan does nothave to pay forthe periodontal scalings (D4341 x4) provided on December 13, 2019 and December 17, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve the Prolia. You say that the enrollee has tried numerous other
bisphosphonates and would benefit from use of Prolia at this time. The Plan denied your request. The Plan says
there is no evidence that the use of zoledronic acid would be harmful or less effective than Prolia.
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 the Prolia. Our reviewer says that the
requested drug is not considered reasonable and necessary based on step therapy rules. Our physician reviewer
found the enrollee is a female with osteoporosis, no history of osteoporotic fracture reported; she has taken
alendronate, Boniva and Forteo in the past. Prolia is now requested. There is no evidence that she has tried and
failed zoledronic acid. The provided medical records do not indicate that the Plan's required drug 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 the Prolia have not been met. Therefore, we decided that the Plan does not have
to pre-approve Prolia (denosumab) injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental extraction (D7140) October 30, 2019.You asked the Plan to pay for the dental services. You say that the primary cause contributor to the extraction of your teeth was the radiation therapy. Without the radiation therapy, the extraction of your teeth would not have been necessary.The Plan denied your request. The Plan says thisis 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 pay fordental extraction (D7140) October 30, 2019.