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

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve these services. You say that the enrollee's current equipment no longer meets his needs. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The item at issue is a power seat elevation feature described by code E2300. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty foldable power wheelchair (PWC) with extra seat cushion and battery.
You asked the Plan to pre-approve a heavy duty foldable power wheelchair with extra seat cushion and battery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested items.
The Plan must follow Medicare rules. Medicare rules say that a Heavy Duty PWC is covered for a beneficiary weighing 285 - 450 pounds. Review of the file shows that the enrollee does not weigh between 285 to 450 pounds. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy duty foldable power wheelchair with extra seat cushion and battery have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty foldable power wheelchair (PWC) with extra seat cushion and battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) provided on October 1, 2019 by an out-of-network provider.
You asked the Plan to pay for the lens. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The limited medical information from your appeal states you have recently had eye surgery. Under Medicare guidelines,
your request for reimbursement of progressive lens(es) is not a covered benefit. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) provided on October 1, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that thePlan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visit. You say that this provider was very helpful to you in the past.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-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-approvethe medical services to be provided by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy - molar
(D3348) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied
your request. The Plan says this is not listed as 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
(D3348) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve retreatment of previous root canal therapy - molar (D3348) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit services provided on December 5, 2019.You asked the Plan to waive the copayment for the specialist office visit services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services provided in a specialist's office on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). We looked at the file, the Plan's contract and Medicare rules. The file shows you received services provided in a specialist's office on December 5, 2019. You have been asked to pay a $50 copayment for the specialist office visit services. The specialist office visit services fall within the Physician/Practitioner services 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 the specialist office visit services provided on December5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device for the enrollee.You asked the Plan to pre-approve the requested device. You say that the device would provide significant clinical and quality of life benefits for the enrollee.The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as decompression.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 requested device. Our physician reviewer found that the requested device is considered experimental. More research is needed to determine its efficacy. Therefore, the device is not medically reasonable and 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 requested device have not been met.Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says a repeat injection is not covered.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the documentation indicates that the previous injection of hyaluronic acid did not improve your symptoms of right knee pain. According to the Medicare rules, a repeat injection is only covered if there is significant improvement in knee pain and known improvement in functional capacity documented in the records. The review has determined that the requested Hyaluronan injection is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar-sacral orthosis and the shoulder-elbow-wrist-hand orthosis provided on November 4, 2019 and November 5, 2019.You asked the Plan to pre-approve the lumbar-sacral orthosis (L0650) and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says the orthoses were not medically necessary.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the lumbar-sacral orthosis (L0650)and the shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer found the enrollee presented with back pain and chronic bilateralshoulder pain, as well as neck pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. Examination of the spine revealed full range of motion and good posture. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. Examination of the upper extremities was normal overall.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 lumbar-sacral orthosis (L0650)and the shoulder-elbow-wrist-hand orthosis (L3960) have not been met.Therefore, we decided that the Plan does not have to pre-approve the lumbar-sacral orthosis and the shoulder-elbow-wrist-hand orthosis provided on November 4, 2019 and November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.You asked the Plan to pre-approve Rituxan. You say that alternate drug(s) contraindicated or previously tried. You also say that there was an adverse outcome.The Plan denied your request. The Plan says in order for Rituxan to be approved, you must use it in combination with Methotrexate unless contraindicated or intolerant. The Plan also says that there was no information provided that showed this.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 Rituxan. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the enrollee has not trialed and failed Remicade or Inflectra; and Simponi Aria. The reviewer also found that the documentation does not support that Remicade or Inflectra; and Simponi Aria would likely be less effective, and/or would likely 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 Rituxan have not been met.Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4241 and D4565).You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this 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 (D4241 and D4565) are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve dental services (D4241 and D4565).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on January 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on January 21,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet the coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered when the beneficiary has
been using a BGM and performing frequent (four or more times a day) testing and is insulin-treated with
multiple (three or more) daily injections of insulin.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a CGM have not been met. Specifically, the records show that the enrollee is
testing less than four times a day and is treated with fewer than three daily insulin injections. Therefore, we
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hand prosthesis (HCPCS L7499)You asked the Planto pre-approve the prosthesis. You say that this is medically necessary.The Plan denied your request. The Plan says this is incorrect coding.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the definition of HCPCS code L7499 is "upper extremity prosthesis, not otherwise specified."We find that HCPCS code L7499 is not supported in the medical record. Specifically, coding guidelines say that this code may not be used. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approve a hand prosthesis (HCPCS L7499)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral -complete series of radiographic images (D0210) provided on October 31, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this service can only be done once every 36 months.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. You exhausted your benefit frequency limit, because the records show that this service was performed on February 1, 2018. Your EOC clearly states, intraoral complete series (including bitewings) limited to once per provider every thirty-six (36) months.Therefore, we decided that the Plan does not have to pay for intraoral -complete series of radiographic images (D0210) provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 17, 2019 from an out-of-network hearing provider.You asked the Plan to pay for the hearing aids. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says hearing aids and routine hearing services are not covered by your Medicare plan.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 this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Review of the file show that you received hearing aids provided on July 17, 2019 from an out-of-network hearing provider. Your EOC states, when hearing services are received from a network supplemental hearing provider, they will be covered as follows: Plan approved hearing aid(s) (1 per ear per year) Up to two hearing aids every year. Benefit is limited to the Advanced and Premium hearing aids, which come in various styles and colors. You must see your network hearing provider to use this benefit. However, you did not use a network provider.Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 17, 2019 from an out-of-network hearing provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on July 19, 2019.You asked the Plan to pay for the hearing aids. You say that you were not aware you had to use group approved vendor.The Plan denied your request. The Plan says that the hearing benefit is not covered if the services are not ordered through the designated vendor.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. The Plan pays for hearing aids only when ordered directly from provider. We looked at the file and the Plan's rules. The file indicates the hearing aids were not ordered from provider.Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids provided on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 28, 2019 through April 29, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnightsor more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found observation care for the following 24 hours or so would have been appropriate for this patient according to the records. Correction of the dehydration and follow-up testing after initiating antibiotics to confirm appropriate response would not require at least two midnights, therefore, criteria is not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from April 28, 2019 through April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pay forsupplies for maintenance of non-insulin drug infusion catheter, per week (A4221) provided to the enrollee from April 11, 2019 through April 17, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the records do not support this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met.Healthcare Common Procedure Coding System (HCPCS) code A4221 (1 Unit) remains not supported. The documentation submitted did not include a valid physician order for the billed date of service. The submitted order was signed and dated by the ordering physician on January 27, 2020and the billed date of service is April 11, 2019 through April 17, 2019; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.Therefore, we decided that the Plan does not have to pay forsupplies for maintenance of non-insulin drug infusion catheter, per week (A4221) provided to the enrollee from April 11, 2019 through April 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 2 power wheelchair, accessories, and Seat Elevator.You asked the Plan to provide a Group 2 power wheelchair, accessories, and Seat Elevator. You say that the enrollee needs the PMD. The Plan denied your request. The Plan says medical necessity for the accessories is not supported in the documentation.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that criteria is not met for the accessories and features. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to providea Group 2 power wheelchair, accessories, and Seat Elevator.