Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Daavlin ultraviolet device.

You asked the Plan to pre-approve the device. You say that this is recommended by the treating dermatologist.
The Plan denied your request. The Plan says this request cannot be approved at this time, as there is no
diagnosis of general intractable psoriasis.

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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, you have a diagnosis of generalized psoriasis. The record does not provide justification
for home therapy over therapy at an outpatient facility. The elements of the coverage rule are not satisfied.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Daavlin ultraviolet device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary for the treatment of
incomplete closure of the eyelid. The Plan denied your request. The Plan says the requested use is not
supported by the FDA and/or nationally recognized compendia.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the requested
treatment with Botox for paralytic lagophthalmos does not meet Medicare coverage criteria. Although there are
published reports of successful treatment of exposure and lagophthalmos using Botox, the standard of care is
still tarsorrhaphy and the use of Botox is covered for only very specific conditions under Medicare guidelines.
The health plan's denial and argument are valid in this situation.

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 a Botox injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions (D7140) to be performed by an out-of-network provider.

You asked the Plan to pre-approve the extractions. You say that the services are medically necessary. The Plan denied your request. The Plan says out-of-network dental care is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve tooth extractions (D7140) to be performed by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home speech therapy visits.

You asked the Plan to pre-approve additional home speech therapy visits. You say that additional home speech therapy is medically necessary. The Plan denied your request. The Plan says additional home speech therapy is not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional home speech therapy visits. Our reviewer says that additional home speech therapy is not medically necessary. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior speech therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a speech therapist. You have minimal speech and swallowing deficits you have been instructed in safety, aspiration precautions, and home exercises. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home speech therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home speech therapy visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional skilled nursing visits (G0299 x14).

You asked the Plan to pre-approve the additional skilled nursing visits. You say that you would like additional skilled nursing visits because you have not learned how to use the blood pressure cuff. The Plan denied your request. The Plan says this request does not meet criteria.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional skilled nursing visits. Our reviewer says that the requested additional home health nursing services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services to provide treatment that is medically necessary. Our reviewer found that you do not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our physician reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 additional skilled nursing visits (G0299 x14).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950).

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 are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental services (D2950).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Carboplatin, Gemcitabine and Pembrolizumab.

You asked the Plan to pre-approve Carboplatin, Gemcitabine and Pembrolizumab. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Carboplatin, Gemcitabine and Pembrolizumab. Our reviewer says that Carboplatin, Gemcitabine and Pembrolizumab are medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has slight progression on single agent chemotherapy in one area with response in another area. The addition of chemotherapy is employed as a standard of care in some patients when radiation is not felt to be a suitable option. The requested drugs are reasonable and medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Gemcitabine and Pembrolizumab have been met. Therefore, we decided that the Plan has to pre-approve Carboplatin, Gemcitabine and Pembrolizumab.

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 hearing aids (V5060) received on November 17, 2020.
You asked the Plan to pay for hearing aids. You say that you would like the Plan to pay for the items. The Plan denied your request. The Plan says the items were received from a non-participating provider and are not covered.
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 you utilize the Plan's hearing aid vendor. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5060) received on November 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve astigmatic keratotomy.
You asked the Plan to pre-approve the procedure. You say that this will help your quality of living. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve astigmatic keratotomy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound (76642) provided on
February 25, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

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 $100
copayment per day for a Medicare-covered ultrasound.

You have been asked to pay a $100 copayment for the Medicare-covered ultrasound provided. 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 breast ultrasound (76642) provided on February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).

You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable oxygen concentrator is medically necessary. The Plan denied your request. The Plan says the enrollee already has oxygen equipment for home use. Equipment for use outside the home is non-covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmology visit (99213, 92134) provided on January 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an OON ophthalmology visit. You say that the enrollee did not update their insurance information. The Plan denied your request. The Plan says this was not authorized.
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 had network providers available who could have provided 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 an ophthalmology visit (99213, 92134) provided on January 18, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient surgery to be provided by an out-of-network
(OON) provider.

You asked the Plan to pre-approve the inpatient surgery. You say that the service is medically necessary. The
Plan denied your request. The Plan says the provider is out-of-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 care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the inpatient surgery 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 dental services (D2950).
You asked the Plan to pre-approve the services. You say that you disagree with this denial and would like it
reconsidered. 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 are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental services (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the consultation. You say that you were seen by this provider for a second
opinion concerning a pain, disbalance, and difficulties walking caused by another surgeon. 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the consultation to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for dental services with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you are having lots of problems with your teeth. The Plan denied your request. The Plan says there is no gap issue and there are network providers available.
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. The Plan covers dental services when provided by network dentists. The requested provider is not in the plan's dental network. Based on this information, we decided that the Plan's rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for dental services with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 2, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there is no referring 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 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 had network providers available who could have provided 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 lab work provided on November 2, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0210, D1110, D0120) received February 10, 2021 from the out-of-network provider.

You asked the Plan to pay for the dental services. You say that the Plan should pay for the requested services. The Plan denied your request. The Plan says the requested services are not covered when received from an out-of-network provider.

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 when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the dental services (D0210, D1110, D0120) received February 10, 2021 from the out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-emergency ambulance transportation (A0428).

You asked the Plan to pre-approve the transportation service. You say that the enrollee requires ambulance transportation from their current assisted living facility to a new assisted living facility. The Plan denied your request. The Plan says Medicare only covers ambulance transportation to the closest facility needed receive medically necessary care. The Plan also says that Medicare does not cover transport from one residence to another.

The Plan must follow Medicare rules. Medicare rules say that the transport must be to obtain a Medicare covered service, or to return from such a service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation service have not been met. The record shows that the enrollee will not be transported to obtain a Medicare covered service, or to return from such a service. Therefore, we decided that the Plan does not have to pre-approve a non-emergency ambulance transportation (A0428).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information provided does not show that it has been at least one week since
the initial injection or block.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found 80% pain relief was not achieved after the diagnostic medial branch block. The pain was 2/10 before the
diagnostic cervical medical branch block and was 9/10 later that day. The block should be interpreted as
negative and should not be repeated.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve paravertebral facet joint injections.