Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occupational therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON occupational therapy. You say that this is medically necessary. The Plan denied your request. The Plan says these services are available from in-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the occupational therapy services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.

You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan
denied your request. The Plan says the requested Procrit is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Procrit. Our reviewer says that the
requested Procrit is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of
Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified
chronic kidney disease. It is noted that the enrollee has anemia of chronic kidney disease. There is no
documentation of symptoms. The enrollee's hemoglobin was 10.2 g/dL. The treatment listed
included the continuation of Procrit injection every 6 weeks. The case file does not contain documentation of
transferrin saturation and ferritin levels.

Epoetin alfa is indicated in patients for the treatment of anemia due to chronic kidney disease, including
patients on dialysis and not on dialysis to decrease the need for red blood cell transfusion.

The documentation is insufficient to demonstrate that Procrit is safe and effective and otherwise reasonable and
necessary for the enrollee in this case. With no documentation of symptoms, no documentation that the
medication is ordered to decrease the need for red blood cell transfusion, and no documentation of transferrin
saturation and ferritin levels, it cannot be determined that the requested Procrit is safe and effective and
otherwise reasonable and 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 Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued financial assistance with room/board/care.
You asked the Plan to pre-approve the continued financial assistance. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. The services at issue in this case do not involve any regular skilled medical/paramedical care. For this reason, the services for which coverage is requested are considered as custodial care. As such, they do not fall into a covered Medicare benefit category. The Plan has indicated this coverage has been provided as a courtesy to offset your living costs. This is not a listed supplemental benefit offered by your specific plan. We find that no Medicare coverage exists for the requested services.
Therefore, we decided that the Plan does not have to pre-approve continued financial assistance with room/board/care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular implant /abutment supported removable denture for edentulous arch (D6111).
You asked the Plan to pre-approve the mandibular implant /abutment supported removable denture. You say that you would like this service approved 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 mandibular implant /abutment supported removable denture for edentulous arch (D6111).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima (Q5115).
You asked the Plan to pre-approve Truxima. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Truxima. Our reviewer says that the criteria for coverage of Truxima have not been met. Our physician reviewer found the Plan requires a trial of Rituxan (rituximab) or Ruxience (rituximab-pvvr) before they will approve the requested drug. The documentation does not support that the enrolee has tried Rituxan (rituximab) or Ruxience (rituximab-pvvr), or that these drugs would likely be less effective or have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima (Q5115).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network office visits.

You asked the Plan to pre-approve out-of-network office visits. You say that you need a new pain management specialist. The Plan denied your request. The Plan says there are in network providers who can provide the same care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out-of-network office visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a True Balance 3 Static Seat (K0108) and replacement calf pads (E0995).
You asked the Plan to pre-approve a True Balance 3 Static Seat and replacement calf pads. You say that the enrollee has a qualifying diagnosis and meets all Medicare guidelines for the requested equipment. The Plan denied your request. The Plan says rules for pre-approval have not been met.
The Plan must follow Medicare rules. Medicare rules say that wheelchair seat and back cushion codes are all-inclusive. Medicare rules also say that replacement codes are not used at the time of initial issue. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the True Balance 3 Static Seat (K0108) and calf pads (E0995) have not been met. Specifically, wheelchair seat and back cushion codes are all-inclusive. The True Balance 3 Static Seat is not separately covered. The calf pads at issue are included in the Plan-approved Group 3 power wheelchair (K0848) and are not separately covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a True Balance 3 Static Seat (K0108) and replacement calf pads (E0995).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 15, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you had a positive Cologuard test and your doctor suggested that you have a follow-up colonoscopy as a part of routine screening. You say this should be a screening colonoscopy. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for each in-network Medicare-covered ambulatory surgical center visit. You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgery centers" benefit category. The medical record shows the colonoscopy was performed due to a positive Cologuard test. Therefore, the colonoscopy diagnostic in nature. 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 the colonoscopy provided on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) provided on October 17, 2020.
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable as they were purchased from an out of network provider, who is not certified by Medicare.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these items have not been met. Specifically, the hearing aids were purchased from an
out-of-network provider, that does not participate in the Medicare program. The Plan contract says that hearing aids ordered through providers other than a Plan contracted provider are not covered. Additionally, if you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) provided on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

We looked at the file and Medicare rules. Review of the file shows that no medical records were submitted to support that the chiropractic services received were for the purpose of manual manipulation of the spine to correct subluxation. Based on this information, we decided that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve purchase of a portable oxygen concentrator.

You asked the Plan to pre-approve the purchase. You say that the portable oxygen tank you have is very heavy and you cannot carry it. The Plan denied your request. The Plan says they will approve the rental of a portable oxygen concentrator (E0431) but purchased oxygen equipment is statutorily non-covered.

The Plan must follow Medicare rules. The rules say that only rented oxygen equipment is eligible for coverage. 

We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the purchase have not been met. Therefore, we decided that the Plan does not have to pre-approve purchase of a portable oxygen concentrator.

Please note, the Plan has approved the rental of a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture reline (D5761) provided on December 8, 2020.
You asked the Plan to pay for the dental service. You say that you have been paying for dental coverage all year. You also say that you feel the service should be covered. The Plan denied your request. The Plan says the denture reline is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the denture reline is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture reline (D5761) provided on December 8, 2020.
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 clinical information provided supports the need for care in a SNF. The Plan denied your request. The Plan says the guidelines for coverage of 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 in the Medicare rules section 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 has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The enrollee continues to make progress with daily skilled therapy services. He could benefit from continued intermittent services at a lower level of care after discharge from the IRF. The enrollee is making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. He can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is 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 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 pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete dentures. You say that the bottom part of your current denture is broken. The Plan denied your request. The Plan says these services exceed the maximum count 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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
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 enrollee requires care in an IRF in order to get home and back to normal. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the services needed can be provided in another setting.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for non-surgical treatment of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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: 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 enrollee requires rehabilitation and does not want it through a skilled nursing facility. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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 pay for the resin-based composites of one surface (D2391) and resin-based composites of two surfaces (D2392).

You asked the Plan to pay for the resin-based composites. You say that you were not advised that these services were not covered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that the provider's office confirmed that you were fully aware these services would not be 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.

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 resin-based composites of one surface (D2391) and resin-based composites of two surfaces (D2392).