Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam tablet 0.5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested medication is denied due to a benefit exclusion.
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 Lorazepam tablet 0.5mg for
the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428, A0425) provided on December 23, 2020.

You asked the Plan to pay for non-emergency ambulance transportation. You say that the service was medically necessary, and you would like reimbursement. The Plan denied your request. The Plan says the service at issue was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for non-emergency ambulance transportation. Our reviewer says that the service was not medically necessary. Our physician reviewer found the documentation does not support that other means of transport, namely stretcher or wheelchair van, would be contraindicated for this enrollee. There was no documentation to show that the enrollee required expertise or special equipment during transport.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428, A0425) provided on December 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol capsule 5mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under the medical plan.

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 Dronabinol capsule 5mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471).
You asked the Plan to pre-approve the removal of lateral exostosis. You say that this service is absolutely vital in order to ensure the highest level of treatment for the enrollee. The Plan denied your request. The Plan says this service is not covered 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 a removal of lateral exostosis (D7471).
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 this is medically necessary. The Plan denied your request. The Plan says your needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the submitted medical records, you do not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the dental item. You say that the denture should be covered. The Plan denied your request. The Plan says an upper denture is covered once every 5 plan years. The Plan also says that the frequency limit has been reached.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and complete upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture that you received on February 26, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostheses identified with codes L5981 and L5986.

You asked the Plan to pre-approve prostheses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are 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 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 prostheses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is ambulating at a K2 level and uses a cane to assist when ambulating and also a power wheelchair in the community. The enrollee's current prosthesis is worn and the exam indicates it is loose fitting. The requested prosthesis is indicated for a level 3 ambulator. A level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands
prosthetic utilization beyond simple locomotion. At this time, the documentation does not support that the
enrollee is a K2 ambulator and therefore, the requested components for the prosthesis are 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 prostheses have not been met. Therefore, we decided that the Plan does not
have to pre-approve prostheses identified with codes L5981 and L5986.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 services provided by an out-of-network provider on January 26, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 13, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare
denied coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for patients with
suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for genetic testing by a contract provider. The file does not show that the plan
provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is
considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on
November 13, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Continuous Positive Air Pressure (CPAP) machine rental provided January 3, 2021 to April 3, 2021.

You asked the Plan to waive the coinsurance for the CPAP machine rental. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 20% coinsurance for durable medical equipment. 

You have been asked to pay a 20% coinsurance for the CPAP machine rental. The CPAP machine rental falls within the durable medical equipment 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 coinsurance for a Continuous Positive Air Pressure (CPAP) machine rental provided January 3, 2021 to April 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided April 15, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that the service should be covered. 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the Emergency Care 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 an emergency room visit (99283) provided April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam with photos (92250) provided on March 2, 2021.

You asked the Plan to waive the copayment for a medical eye exam. You say that the reason for your visit was to check your vision and see if you needed stronger glasses. The Plan denied your request. The Plan says the copayment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for a medical eye exam.

You have been asked to pay a $29.42 copayment for a medical eye exam. The records show you had an office visit and a medical eye exam with photos. The records also show that you are no longer liable for the office visit but now have a cost share for your eye exam. The EOC confirms that $50 is the required copayment for this service. You have been asked to pay a copayment of $29.42, which is less than the Plan's contracted amount. 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 a medical eye exam with photos (92250) provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865).

You asked the Plan to pre-approve the complete mandibular overdenture. You say that you need this
overdenture to be able to eat. The Plan denied your request. The Plan says this service is not covered under
your 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 a complete mandibular overdenture (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and mandibular interim partial denture (D5821).
You asked the Plan to pre-approve the complete maxillary denture and mandibular interim partial denture. You say that the enrollee has not been able to wear the dentures she has. The Plan denied your request. The Plan says the complete maxillary denture exceeds the maximum count allowed per period. The Plan also says that the mandibular interim partial denture is not covered 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, mandibular interim partial denture (D5821) is not among those covered under this benefit. The contract says that complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that the enrollee received a complete maxillary denture (D5110) on September 12, 2018 and the enrollee's complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and mandibular interim partial denture (D5821).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain.
You asked the Plan to pre-approve the scan. You say that the enrollee has frontal/temporal dementia with a behavioral variant. The Plan denied your request. The Plan says this is not covered by Medicare or the health plan.
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 the scan. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you are noted to have some memory problems, but the provider's notes stated that you did not meet diagnostic criteria for dementia. Rather, you were noted to have some mild memory deficits. The notes did not support that you meet the diagnostic criteria for AD and FTD. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate that you have 3/5 left upper extremity strength and left upper extremity fine motor function which is within functional limits. You perform self-catheterization, thus indicating adequate left upper extremity strength and function to operate the power options with their own switches. 

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 additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips (A0100).
You asked the Plan to pre-approve additional transportation trips. You say that you need the Plan to pre-approve additional trips so you can get to dialysis 3 times a week. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
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 24 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 additional transportation trips (A0100).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam cap 15mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary, as the enrollee is unsuccessful is controlling his insomnia. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.

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 Temazepam cap 15mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J1561) provided January 15, 2021.

You asked the Plan to waive the coinsurance for the injections. You say that the copayment should be waived because the maximum out-of-pocket amount was reached. The Plan denied your request. The Plan says the correct cost-sharing 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 20% coinsurance for Part B drugs.

You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B drugs benefit category. The $2,000 out-of-pocket maximum was not yet met at the time the services were rendered. 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 coinsurance for injections (J1561) provided January 15, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the heart for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this test is not medically necessary as a standalone test.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has an intermediate risk for cardiovascular disease, based on the American College of Cardiology cardiovascular risk calculator, and some clinical findings to suggest cardiovascular disease as well. She is not currently on statin therapy, and given the intermediate risk, the applicable guidelines support the use of CT calcium scoring to further stratify her cardiovascular disease risk. As such, since the results of the scan will provide new and additional information which will facilitate her medical management, it meets the medical necessity criteria of the applicable CMS rules for use of CT scanning. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the heart for the enrollee.
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