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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that you should be able to have the requested items are preventing blood clots is important for maintaining your health. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6533 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.

You asked the Plan to pre-approve the compression stockings. You say that the enrollee's finances are limited. He cannot afford to pay out of pocket for the garments that are necessary for his care.

The Plan denied your request. The Plan says the criteria for coverage of one pair of stockings has been met. The request for 2 pairs of stockings exceeds the Plan's quantity limits.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

In this case the Plan has approved 1 pair of the requested compression stockings. The Plan's medical policy allows for coverage of one single pair of stings every 6 months for enrollee's that meet the medical criteria for coverage. The plan agrees that the enrollee meets the medical criteria for coverage. The request for 2 pairs is above the allowed quantity per 6-month period. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that custom molded orthotics have been recommended to treat and manage the enrollee's bilateral plantar fasciitis. 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 the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network
(OON) provider.

You asked the Plan to pre-approve podiatry services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.

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 podiatry services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a handheld massager.

You asked the Plan to pre-approve a handheld massager. You say that you need a handheld massager for your
legs to assist with circulation. The Plan denied your request. The Plan says a handheld massager is not covered
because it is not medical in nature and is regularly and primarily used by persons who do not have a specific
medical need for it.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a handheld massager.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, problem focused (D0140)
received February 19, 2021.

You asked the Plan to pay for the limited oral evaluation, problem-focused. You say that you trusted the Plan
and thought that this visit would be covered. The Plan denied your request. The Plan says the requested service
is not covered under your supplemental 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
limited oral evaluation, problem focused (D0140) received February 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve genicular RFA. You say that the enrollee would benefit from this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is still being studied in trials for efficacy in this setting.
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 genicular RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of ongoing clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
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 enrollee requires specialized mid-to-long term acute care treatment and is too complex for skilled nursing care at this time. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: 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 services are medically
necessary. The Plan denied your request. The Plan says LTACH care is not medically required at this time.

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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right total shoulder arthroplasty.

You asked the Plan to pre-approve shoulder surgery. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not medically necessary for your condition.

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 shoulder surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe osteoarthritis of the shoulder and a septic joint. The record indicates that this surgery will not be performed now due to the infection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve right total shoulder arthroplasty.
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 is at risk of falling and needs monitoring of her condition. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While the enrollee requires physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services 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 a health club membership (S9970) for the months of January 2020 and February 2020.
You asked the Plan to pay for the health club membership. You say that you purchased an annual membership for two people and feel you should be reimbursed for half of the total cost for the 2020 membership. The Plan denied your request. The Plan says that they have provided reimbursement for the months of March through October 2020, when you were both an active member of the Plan and maintained the health club membership. However, reimbursement cannot be provided for the months of January and February, as you were not a member of the Plan at the time and therefore ineligible to receive benefits.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only for enrolled Plan members. The Plan's rules for coverage of gym benefits have not been met because you were not a member of the Plan during the months of January 2020 and February 2020. The Centers for Medicare and Medicaid Services shows that you enrolled with the Plan on March 1, 2020, and were not previously a member with this Plan. You purchased a health club membership from January 2020 to October 2020, and the Plan provided reimbursement for the months that you were enrolled in both the Plan and the health club. Therefore, we decided that the Plan does not have to pay for a health club membership (S9970) for the months of January 2020 and February 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two core buildups (D2950), two porcelain/ceramic crowns
(D2740), periodontal scaling and root planing (D4341) for four quadrants and oral hygiene instructions
(D1330) provided on March 5, 2021.

You asked the Plan to pay for the dental services. You say that you called the Plan prior to services to verify
your coverage, and you were told that you were all set to start receiving comprehensive dental care. The Plan
denied your request. The Plan says you were informed prior to your dental appointment that the optional
comprehensive plan was not active as the paperwork had not been received yet, but that you were still able to
get preventative dental care until then. These services are not covered by the preventative dental Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for two core buildups (D2950), two porcelain/ceramic crowns (D2740), periodontal scaling and root planing (D4341) for four quadrants and oral hygiene instructions (D1330) provided on March 5, 2021.

Your complaint about a possible miscommunication regarding your benefits prior to services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 you have been working with a skilled nurse a few times a week with no results. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 you were admitted for atrial fibrillation and pain after a recent total knee replacement. You are living in an assisted living facility with ongoing pain and difficulty ambulating. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral salpingectomy for sterilization.

You asked the Plan to pre-approve the procedure. You say that the enrollee has multiple medical and mental
conditions that would be greatly intensified by pregnancy. The Plan denied your request. The Plan says this is
not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that surgery for the purpose of sterilization is
generally not covered.

This surgery is being requested as a preventative measure, rather than being requested as part of treatment for
an illness or injury. Based on this information, we decided that Medicare rules for coverage of the procedure
have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral salpingectomy
for sterilization.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Urolift procedure.

You asked the Plan to pre-approve Urolift. You say that delay of this procedure will cause more discomfort, difficulty voiding, and possibly a trip to the emergency room. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee does not meet the criteria for Urolift.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Urolift. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the Urolift system is Food & Drug Administration (FDA) cleared for the treatment of symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia. In addition, the enrollee has failed medical therapy as indicated by the presence of a large bladder stone and worsening voiding symptoms. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Urolift have been met. Therefore, we decided that the Plan has to pre-approve the Urolift procedure.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received February 2, 2021.

You asked the Plan to pay for the limited, problem focused evaluation. You say that your dentist office told you that you would not owe any money. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 limited oral evaluation - problem focused (D0140) received February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for DME and related supplies provided on January 25, 2021.

You asked the Plan to waive the deductible for DME and related supplies. You say that you have a rental agreement and should not owe anything for the DME and related supplies starting in January 2021. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible for DME and related supplies. 

You received DME and related supplies on January 25, 2021. The record shows that you had paid $0 toward the $203 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $181.73.

The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for DME and related supplies. This cost sharing is a contractual obligation that had not been met at the time DME and related supplies were received on January 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for DME and related supplies provided on January 25, 2021.