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

We decided that the Plan does not have to pre-approvethe RYBO Air Balance Custom Brace.You asked the Plan to pre-approvethe RYBO Air Balance Custom Brace. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plansays the requested custom bilateral AFO's are not shown to be currently medically necessary or reasonable and studies have not shown that these custom balance braces improve balance or prevent falls.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 RYBO Air Balance Custom Brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is not clear from the provided medical records how the custom fabricated bilateral ankle ankle-foot orthoses (RYBO Air Balance Custom Braces) in this case would specifically benefit 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 RYBO Air Balance Custom Brace have not been met.Therefore, we decided that the Plan does not have to pre-approvethe RYBO Air Balance Custom Brace.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you were not aware that prior authorization was necessary.The Plan denied your request. The Plan says an authorization for out-of-network services 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 forthe medical services provided on July 1, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services provided on July 
12, 2020. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says you were charged this copayment 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 $50 
copayment for urgent care services.  
 
You have been asked to pay a $50 copayment for the urgent care services. his 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 the urgent care services provided on July 12, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 28. 
 
You asked the Plan to pre-approve the dental service. You say that tooth # 28 has an extensive restoration with 
risk of fracture if proper protective restoration is not done. You also say that the enrollee has heavy bruxism. 
The Plan denied your request. The Plan says that tooth # 28 has a clinically unacceptable root canal fill. The 
Plan also says that placing a crown on tooth # 28 in its current state is not covered. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the crown is medically necessary. Our physician reviewer found the provided documentation indicates that 
a root canal has been completed on tooth #28. The reviewer found that the root canal for tooth # 28 appears 
adequate. The reviewer found there is significant breakdown of the coronal aspect of tooth #28. Therefore, the 
reviewer found that a crown restoration is reasonable and necessary to restore the tooth to proper function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2750) for tooth # 28.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs or any reason why they would be unsafe or ineffective 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture. 
 
You asked the Plan to pre-approve the denture. You say that this is medically necessary, as your lower denture 
broke when you were having two crowns done. The Plan denied your request. The Plan says the benefit has 
been exhausted for the 2020 plan year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dentures once 
every five years. 
 
The records show that this same service was last provided on February 25, 2019. Based on this information, we 
decided that the Plan's rules for coverage of the denture have not been met. Therefore, we decided that the Plan 
does not have to pre-approve mandibular partial denture.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services received on April 15, 2020. 
 
You asked the Plan to pay for . You say that you would like plan to reconsider their denial. The Plan denied 
your request. The Plan says that the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the documentation shows that the file was largely incomplete when 
submitted to the IRE. No claim was provided to show the laboratory services received. An initial decision 
letter was also not provided. A request for this information was requested by the IRE and was not received. 
The plan did not substantiate their denial by providing the required documentation needed to review this case. 
Therefore, we decided that the Plan has to pay for the laboratory services received on April 15, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and routine 
electrocardiogram (EKG) (99285, 93010) provided on May 26, 2020. 
 
You asked the Plan to pay for the emergency department visit and EKG. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the member was enrolled 
in hospice at the time of the service and the claim should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit and routine 
electrocardiogram (EKG) (99285, 93010) provided on May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the femur (73551) provided June 2, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the procedure was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73551 is not supported in the medical record. Specifically, the RT modifier was 
submitted indicating the x-ray was performed on the right femur, however, the diagnosis code billed indicates a 
problem with the left side. Based on this information, we decided that Medicare rules for coverage of the x-ray 
have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the femur (73551) 
provided June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical treatment for a hip fracture and was treated for pneumonia. Medical problems are stable. 
There are no identified problems that need inpatient medical management. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on April 29, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that you cannot afford this copayment at the moment. The Plan denied your request. The Plan says the correct copayment has been 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 $150 copayment for ambulance services/one-way ground. You have been asked to pay a $150 copayment for an ambulance trip. An ambulance trip falls within the ambulance services/one-way ground 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 ambulance trip provided by a participating provider on April 29, 2020. We note your complaint about not being apple to afford this. Your complaint is a grievance that must be answered by the healthplan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 10, 2020.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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. This provider is not a network provider. We have also determined thatthese services are not urgent or emergent, nor were they approved in advance.The Plan must follow Medicare rules. Medicare rules say that a Masters of Social Work is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The provider at issue is a Masters of Social Work.  A Masters of Social Work is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services providedon July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve (CPT Codes 64493, 64495 and 64494). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found first issue is the fact that there is ongoing radiculopathy documented. The LCD requires that the facet 
joints be the probable primary pain generator. The patient has other pain generators documented which have 
not been treated. Second, the patient has had only one set of diagnostic MBBs and not the required dual 
diagnostic blocks. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve (CPT Codes 64493, 64495 and 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not able to function on her own 
without further rehab. The Plan denied your request. The Plan says the enrollee does not need an intensive 
rehab program with the specialized skills and services of a rehab hospital. 
 
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 physician reviewer found 
that the enrollee has a history of pneumonia, arthritis, and hyponatremia. The enrollee demonstrated difficulty 
following simple commands on a clinical swallow evaluation. It is noted that she will remain at risk for 
intermittent aspiration due to her advanced age and generalized weakness. The documentation does not support 
that the complexity of her nursing, medical and rehabilitation needs requires an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. She does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are disabled in a wheelchair and your feet 
twist. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: 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 get dizzy and cannot stand for long. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGemcitabine (J9201) and Docetaxel (J9171).You asked the Plan to pre-approvethe Gemcitabine and Docetaxel. You say that you would like reconsideration because this drug combination is medically necessary.The Plan denied your request. The Plan says this drug or mix of drugs is not supported in the National Comprehensive Cancer Network (NCCN)guidelines or by the Food and Drug Administration (FDA) for the member's condition in this setting.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 the Gemcitabine and Docetaxel. Our reviewer says that the combination is not FDA approved nor is it supported in any of the CMS approved compendia. Our physician reviewer found the documentation does not support that the combination requested is medically reasonable and necessary or safe and effective 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 Gemcitabine and Docetaxel have not been met.Therefore, we decided that the Plan does not have to pre-approveGemcitabine (J9201) and Docetaxel (J9171).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 12, 2019.You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for outpatient surgery. The enrollee has been asked to pay a $300 copayment for an outpatient surgery. The services that were provided are considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 12, 2019.