Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the false teeth over implants (D6110, D6111) and the modification of false teeth (D5875).
You asked the Plan to pre-approve the false teeth over implants (D6110, D6111) and the modification of false teeth (D5875). You say that it is medically necessary that you receive the dentures over the implants. 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 false teeth over implants (D6110, D6111) and the modification of false teeth (D5875) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the false teeth over implants (D6110, D6111) and the modification of false teeth (D5875).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available in the plan's 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 pre-approve 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. 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 a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019 by the out of network provider.
You asked the Plan to pay for the outpatient visit (99203). You say that you were told by your PCP to see a specialist while you were out of state. The Plan denied your request. The Plan says this service was rendered by an out-of-network provider without prior authorization.
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 July 11, 2019 by the out of network provider.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not show the need for the intensity of an IRF stay with close physician or nursing supervision. Your functional status does not require an intensive rehabilitation facility level of 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 3, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug
testing rendered on April 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ED visit provided on August 23, 2019.
You asked the Plan to pay for the ED visit. You say that the claim has not been paid in full or under the terms of the contract. You say that payment should be made. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ED visit provided on August 23, 2019.
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 live by yourself and need the intensive rehabilitation that an IRF would be able to provide so that you can live an independent life. You say that a SNF would not be able to provide the service need. You say that the attending physician at the hospital recommended transfer to an IRF. The Plan denied your request. The Plan says the enrollee does not meet the criteria for transfer to an IRF. The plan says that the enrollee's medical condition will not allow for participation in physical therapy activities for up to 3 hours a day and show that the enrollee needs maximum assistance for bed and mobility transfers.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly total to maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit from and/or participate in an IRF level of 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 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the annual wellness visit you received on May 29, 2019.
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says that you have received the maximum amount of coverage allowed for this type of service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. A review of the plan contract shows that an annual wellness visit is covered once every 12 months. The plan did not provide documentation that you previously received an annual wellness exam within the last 12 months. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the annual wellness visit you received on May 29, 2019.
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 meets the full criteria for an IRF stay. You say that the enrollee's current needs cannot be safely met at a lower level of care. The Plan denied your request. The Plan says the guidelines for IRF coverage have not been met. The plan says that the enrollee can receive care 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and treatment to be provided by an out of network provider.
You asked the Plan to pre-approve out-of-network evaluation and treatment. You say that your doctor has recommended you see an out-of-network specialist. The Plan denied your request. The Plan says care for your condition is available within 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 pre-approve 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. 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 evaluation and treatment to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from August 1, 2019 to October 20, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from
August 1, 2019 to October 20, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose monitor provided  on July 24, 2019.
You asked the Plan to pay for the one-month supply allowance (K0553). You say that you are billing according to Medicare guidelines. The Plan denied your request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules state that a supplier does not have to deliver supplies used with a therapeutic CGM every month in order to bill code K0553 every month. In order to bill code K0553, the supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month following the DOS on the claim. No more than 1 unit of service (UOS) for code K0553 per month is billable at a time. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity of BGM testing supplies at a time. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the one-month supply allowance (K0553) have been met. Specifically, the supplies in this case were delivered in a 90-day supply for K0553, which the Proof of Delivery supports. The supplier is only billing one unit of K0553 at a time for supplies that are sufficient for one full month following the DOS on the claim. The supplier in this case is billing in accordance to Medicare rules for continuous glucose monitoring supplies. Therefore, we decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose monitor provided on July 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network
provider.
You asked the Plan to pre-approve the hospital services. You say that care at an out-of-area hospital is
medically necessary as you do not want your care to be fragmented. The Plan denied your request. The Plan
says on-going care for your condition can be provided 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 pre-approve 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. 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 medical services to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a feeding tray.
You asked the Plan to pre-approve the feeding tray. You say that the enrollee is unable to move by herself and the tray is needed to be able to feed her in bed. The Plan denied your request. The Plan says this item is a convenience item and is not covered.
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 feeding tray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous vision service
You asked the Plan to pre-approve the OrCam My Eye2.0. You say that the medical records provided support
the necessity of the services in dispute. The Plan denied your request. The Plan says this item is not a Medicare
covered benefit.
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 miscellaneous vision service
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on July 11, 2019.
You asked the Plan to pay for the testing services. You say that medical records detail the personal and/or family history of related cancers for the enrollee. The Plan denied your request. The Plan says benefits cannot be provided for services that have been determined not to be medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The file shows that the enrollee received BRAC Analysis testing. The records provided show that the enrollee has no personal history of cancer. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on July 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there was a previous test that showed no changes in the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found according to the Fleischner Society published guidelines for follow-up of pulmonary nodules there is no need to do additional CT scans since the nodules are stable over 24 months and are thus considered benign. The patient does have a smoking history and COPD and MAY be eligible for annual low dose CT depending on her smoking history and satisfaction of CMS guidelines for the test but that determination would be the responsibility of the requesting physician to determine same. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve the Euflexxa injections. You say that this treatment is necessary. The Plan denied your request. The Plan says there is no reason that the plan's preferred drugs could not be used.
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 the Euflexxa injections. Our reviewer says that the use of Euflexxa is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee is a 67 year old man with a diagnosis of Unilateral primary osteoarthritis of the left knee. There is no indication that the preferred drugs have been tried and failed. The documentation does not support that Orthovisc or Monovisc 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 the Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as E0607, A4253, A4259 and A4256 provided August 7, 2019 to October 26, 2019.
You asked the Plan to pay for the diabetic supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the supplies billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number. The proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. The proof of delivery is not itemized to indicate the specific supplies. Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as E0607, A4253, A4259 and A4256 provided August 7, 2019 to October 26, 2019.