Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has several areas that have yet to be delineated. Has malignancy that is too sick for chemo or surgery. Does not take adequate nutrition orally and is not a candidate for a PEG tube. Care is Palliative at this point. With no means of feeding and no specific need that would require/benefit from LTACH placement, the current level of care is appropriate. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy (PBT).
You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is medically necessary for treatment of the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for proton beam therapy is correct, because there is no documentation as to why proton beam therapy is a benefit over standard intensity-modulated radiation therapy which is also highly effective, well-tolerated, and the standard of care.
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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are few studies specifically describing proton beam therapy for pelvic radiation for prostate cancer. These studies are small and do not demonstrate a benefit with respect to toxicity outcomes or disease-free/biochemical progress-free survival. Although proton beam therapy is not experimental, any potential benefit or detriment of proton beam therapy versus standard intensity-modulated radiation therapy for routine cases is investigational at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy (PBT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for a triptorelin pamoate injection
(J3315).
You asked the Plan to pre-approve the tier exception. You say that you would like reconsideration because the
member requires cost sharing assistance. The Plan denied your request. The Plan says tier exceptions (co-pat
reductions) are not available for drugs/devices covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the tier exception have not been met. Specifically, drugs covered under Medicare Part B are not
eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception
for a triptorelin pamoate injection (J3315).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires medical supervision, intensive therapies, and blood pressure monitoring.The Plan denied your request. The Plan says the enrollee does not need to be seen by a rehab doctor three times a week, or an intensive team for 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 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's current level of function is maximum assist for bed mobility and transfers, and standby assist for eating, oral hygiene, and grooming. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. His medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from, physical and occupational therapy, but the documentation does not support thathis functional status requires an 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 notbeen met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on January 14, 2020.You asked the Plan to pay for the extraction. You say that you verified that the provider accepted your insurance, and that the extraction does not present any complications.The Plan denied your request. The Plan says this is not a covered service under your 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, you are responsible for 100% of the cost for Class 3 Major Services.Therefore, we decided that the Plan does not have to pay for the surgical extraction provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for daratumumab injection (J9145x21) provided on September 23, 2019.
You asked the Plan to pay for the daratumumab injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We asked our coder 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 the daratumumab injection. Our reviewer says that CPT code J9145 JW (21 units) does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation that supports the 21 units of drug wasted, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the daratumumab injection have not been met. Therefore, we decided that the Plan does not have to pay for daratumumab injection (J9145x21) provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out of network (OON) provider.You asked the Plan to pay for audiology services. You say that you are appealing for payment.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee meniscectomy (29880).You asked the Plan to pre-approve knee meniscectomy. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 knee meniscectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for a meniscal transplant is not met. There is no documentation of a recent x-ray that shows only mild degenerative joint disease (DJD)and excludes severe DJD in any region of the knee. More information needed at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee meniscectomy have not been met.Therefore, we decided that the Plan does not have to pre-approve knee meniscectomy (29880).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on July 15, 2019, and October 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 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 medical services provided to you by an out-of-network provider on July 15, 2019, and October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-complete series x-ray provided on March 3, 2020.
You asked the Plan to pay for the intraoral-complete series x-ray. You say that you are using an in-network dentist. You say that you were informed you were covered for a cleaning and images as preventive care. The Plan denied your request. The Plan says the service is not a covered benefit.
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 intraoral-complete series x-ray is not the type of x-ray covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-complete series x-ray provided on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite (D2391) provided on February 27, 2020.
You asked the Plan to pay for the resin based composite (D2391). You say that you were at the dentist to have a cavity filled. You say that you don't understand why the claim was denied. The Plan denied your request. The Plan says the service is not a covered benefit.
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 composite (D2391) provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued negative pressure wound therapy pump (NPWT) and supplies use beginning August 22, 2020. You asked the Plan to pre-approve these services. You say that you need to continue to use this device. The Plan denied your request. The Plan says that Medicare guidelines for continued are coverage not met. The Plan must follow Medicare rules. Medicare rules say that continued NPWT use is covered if the above criteria are met. 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 requested items/services are not considered medically reasonable and necessary in this case. One of the criteria for which NPWT pump and supplies will be denied as not reasonable and necessary is: 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound. As it has been greater than 4 months since the NPWT pump was applied for the treatment of the most recent wound, the pump is denied as not reasonable and necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued NPWT use. 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 continued negative pressure wound therapy pump (NPWT) and supplies use beginning August 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for discitis/osteomyelitis. The enrollee is receiving antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currentlyavailable. The enrollee can remain at the current acute care hospital until such time no acute services is required.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodontal evaluation provided on
February 12, 2020.
You asked the Plan to pay for the prophylaxis and periodontal evaluation. You say that you had dental
coverage in 2019 and your plan renewed for 2020 with no changes. You say that you want your dental
coverage reinstated and have the Plan to pay for the services. The Plan denied your request. The Plan says the
contract no longer covers dental services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodontal
evaluation provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build-up (D2950) provided on October 17, 2019 and the crown (D2740), retainer crowns (D6740) and pontics (D6245) October 31, 2019.You asked the Plan to pay forthe core build-up (D2950), crown (D2740), retainer crowns (D6740) and pontics (D6245). You say that you weren't asked if you wanted your crown and caps removed or change. You say that you weren't informed of how much this would cost.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe core build-up (D2950) provided on October 17, 2019 and the crown (D2740), retainer crowns (D6740) and pontics (D6245) October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that the requested items are necessary.The Plan denied your request. The Plan says the items are not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have topre-approvecompression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator extra battery and
charger purchased on January 14, 2020.
You asked the Plan to reimburse you for the extra battery and charger. You say that the purchase should be
covered. The Plan denied your request. The Plan says the items in question are only covered when a
concentrator is rented not as purchase.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Medicare rules say that only rented oxygen equipment is
eligible for coverage.
We looked at this the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by
Medicare. The items at issue were bought for a purchased oxygen concentrator and therefore not covered by
Medicare. Based on this information, we decided that Medicare rules for coverage of the extra battery and
charger have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable
oxygen concentrator extra battery and charger purchased on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on February 4, 2020.
You asked the Plan to pay for shoe lifts (L3332). You say that the enrollee needs the shoe lifts. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for their condition. Therefore, we decided that the Plan does not have to pay for foot orthotics
provided on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on March 16, 2020.
You asked the Plan to pay for the immediate upper denture (D5130). You submitted the denial for review. You say that you are covered for up to $1,000 per year. The Plan denied your request. The Plan says the service is not a covered benefit.
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 immediate upper denture (D5130) provided on March 16, 2020.