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

We decided that the Plan does not have to pre-approve a second opinion for treatment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion for treatment to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 a second opinion for treatment 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 the endodontic therapy, anterior tooth (D3310) and the mandibular partial denture (D5212).
You asked the Plan to pre-approve the endodontic therapy and the mandibular partial denture. You say that the requested services are necessary because the original provider made a mistake. The Plan denied your request. The Plan says the requested services exceed 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 or in excess of this benefit. Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy, anterior tooth (D3310) and the mandibular partial denture (D5212).
Your complaint about receiving poor service from your provider 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parenteral nutrition.
You asked the Plan to pre-approve parenteral nutrition. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Parenteral Nutrition Therapy Daily parenteral nutrition is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition. 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 parenteral nutrition. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that there is no clinical rationale for the requested parenteral nutrition. The records indicate that the enrollee is able to swallow. Medicare does not cover parenteral nutrition when a person can swallow, can get food to the stomach and when a person's intestine works. The review indicates that the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of parenteral nutrition have not been met. Therefore, we decided that the Plan does not have to pre-approve parenteral nutrition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents and periodontal maintenance provided on November 3, 2020.
You asked the Plan to pay for the localized delivery of antimicrobial agents and periodontal maintenance. You say that you have seen this provider multiple times in the past and the services have been covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective January 25, 2016, to January 25, 2022. The Plan also says that services performed by a privately contracted provider are 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. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the localized delivery of antimicrobial agents and periodontal maintenance have not been met. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents and periodontal maintenance provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided by a participating provider.

You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for outpatient diagnostic tests/non-radiological tests.

The enrollee has been asked to pay a $30 copayment and a $24.48 for outpatient diagnostic tests. The total amount you are being asked to pay is $54.48 ($30 + $24.48 = $54.48) which is less than your copayment amount of $60 ($30 x 2 tests = $60). Outpatient diagnostic tests fall within the outpatient diagnostic tests/non-radiological tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided by a participating provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from October 21, 2020, to
October 30, 2020.
You asked the Plan to pay for the SNF services. You say that you received an authorization for the enrollee
when they were admitted to the facility. The Plan denied your request. The Plan says Original Medicare would
be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on October 20, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the SNF services
provided from October 21, 2020, to October 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical component of a foot x-ray from a mobile radiology provider as well as the transportation and setup charges for services provided on October 11, 2020.
You asked the Plan to pay for the technical component and transportation/setup charges. You say that this was medically necessary and should be covered. The Plan denied your request. The Plan says the services billed cannot be paid in the reported POS.
The Plan must follow Medicare rules. Medicare rules say that POS 31 is reported for enrollees in a Part A covered SNF stay. The technical component and transport/setup for mobile radiology services cannot be separately billed for a patient in a covered SNF stay. The POS reported in this case was 31. The billed codes are not separately payable with this POS code. Therefore, we decided that the Plan does not have to pay for the technical component of a foot x-ray from a mobile radiology provider as well as the transportation and setup charges for services provided on October 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two porcelain/ceramic crowns (D2740) for tooth 11 and tooth 12.
You asked the Plan to pre-approve the crowns. You say that these crowns are medically necessary. The Plan denied your request. The Plan says this type of crown (D2740) is not covered by Medicare or by the Plan's supplemental dental 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 two porcelain/ceramic crowns (D2740) for tooth 11 and tooth 12.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services.

You asked the Plan to pay for the home health aide services. You say that these are medically necessary and ordered by the treating physician. The Plan denied your request. The Plan says the provider is not certified by Medicare and, as such, cannot be paid for these services.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Home health aide services are only covered by Medicare when part of a home health plan of care that includes skilled nursing and therapy services.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The services being provided are not Medicare-covered as they are not being provided in conjunction with skilled nursing or therapy services. Therefore, we decided that the Plan does not have to pay for the home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is your option instead of surgery. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided by.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is considered investigational at this time and is not medically necessary.
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 powered upper extremity orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Powered Upper Extremity Orthosis will improve the long-term outcomes for patients, improve hemiparetic arm function, or be safe for long term use. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the powered upper extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says a four-week trial of a basic compression device has not been completed.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that you believe that this is medically necessary for you due to your issues with self-testing with the standard monitor. The Plan denied your request. The Plan says the criteria are not met for the CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. The records document an order for testing only three times daily. Although up to three daily insulin injections are documented in the record, these are for set doses of long-acting insulin. There is no evidence of frequent adjustment of the dose based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
You asked the Plan to pre-approve a PET scan of the brain. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. 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 a PET scan of the brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not demonstrate that the enrollee meets the criteria for both Alzheimer's and fronto-temporal dementia. The elements of the national coverage determination are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided from January 1, 2020, to January 25, 2020.
You asked the Plan to waive the copayment for SNF care. You say that the dates of service that you were in the SNF correspond to 2 different insurance calendar years. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $0 copayment each day for days 1 to 20, a $160 copayment each day for days 21 to 55, and a $0 copayment for additional Medicare-covered days, up to 100 days for Skilled Nursing Facility (SNF) Care up to an in-network maximum out-of-pocket amount of $5,500 for 2020. At the time this claim was processed, $1,986.40 of the $5,500 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 24 days, which were days 23 to 47 of the benefit period, resulting in a total copayment amount of $3,513,60 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $5,500 in-network maximum out-of-pocket amount for 2020. You have been asked to pay a $0 copayment each day for days 1 to 20, a $160 copayment each day for days 21 to 55, and a $0 copayment for additional Medicare-covered days, up to 100 days for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) Care 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 skilled nursing facility (SNF) care provided from January 1, 2020, to January 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that these disposable under pads are medically necessary. The Plan denied your request. The Plan says these are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 6,
2020, to July 10, 2020, and billed under code G0156.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says code G0156 (140 units) remains not supported. The records submitted did not include
time documentation. The Plan notes several attempts were made to request additional information.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when necessary provide specific documentation
to support the services billed. In this case, the records provided do not support the services billed. Based on this
information, we decided that Medicare rules for coverage of this service as billed have not been met. Therefore,
we decided that the Plan does not have to pay for home health services provided to the enrollee from July 6,
2020, to July 10, 2020, and billed under code G0156.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional payment for the routine eyewear provided on June 22, 2020.
You asked the Plan to approve additional payment for the routine eyewear. You say that you cannot afford this. The Plan denied your request. The Plan says that they have provided the correct payment for these services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will provide reimbursement for up to $50 per calendar year towards the purchase of eyeglasses or contact lenses. We looked at the file and the Plan's rules. The file shows that the Plan has provided the maximum yearly benefit of $50 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to approve additional payment for the routine eyewear provided on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc (J7324).
You asked the Plan to pre-approve Orthovisc. You say that the Orthovisc is medically necessary. The Plan denied your request. The Plan says this drug is not covered when provided by a pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Orthovisc (J7324).