Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide and skilled nursing services. 
 
You asked the Plan to pre-approve home health visits. You say that you are appealing with medical records. 
The Plan denied your request. The Plan says the denial of authorization for home health care is correct. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health visits. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health visits. Our physician 
reviewer found the documentation does not support that the enrollee requires help with personal care. There are 
no wounds documented, nor simple dressing changes that do not require the skills of a licensed nurse. The 
documentation does not support that the enrollee requires assistance with medications. There is no 
documentation of assistance with activities that are directly supportive of skilled therapy services but do not 
require the skills of a therapist. There services are not medically reasonable and necessary to the treatment of 
the enrollee's condition by skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide and skilled nursing services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic screening testing.
You asked the Plan to pre-approve genetic testing. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for these tests is correct, because this testing has no relation to the diagnosis or treatment of the enrollee.
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 tests at issue in this appeal, genetic testing, are being requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve genetic screening testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns by an out-of-network provider. 
 
You asked the Plan to pre-approve the crowns. You say that you are appealing the denial. The Plan denied your 
request. The Plan says out-of-network dental 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crowns by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutement, includes placement (D6057) abutment supported porcelain/ceramic crown, teeth 19 and 30 (D6058).
You asked the Plan to pre-approve the dental services. You say that you can't finish restoration with abutements and crowns over implants in 2019 due to this take time for healing. Please consider the enrollee's medical condition and financial difficulties. The Plan denied your request. The Plan says these services are not covered under the plan 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutement, includes placement (D6057) abutment supported porcelain/ceramic crown, teeth 19 and 30 (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the new CGM is medically necessary. The Plan denied your request. The Plan says the enrollee already has a Dexcom G6 CGM. No Clinical records were provided to determine why a Freestyle Libre is needed.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a Dexcom G6 CGM. A Dexcom G6 CGM serves the same purpose as the CGM. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You are generally medically stable and the 
documentation does not support that you have complex medical issues that require acute rehab nursing care, or 
monitoring by an inpatient physical medicine and rehab physician three times per week. While you are 
reasonably expected to benefit from continuing physical therapy (PT) and occupational therapy (OT), the 
documentation does not support that there is need for an intensive therapy program with therapy 3 hours per 
day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy by an out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee would benefit from continued 
treatment to address range of motion, strength deficits and allow improved degree of function. The Plan denied 
your request. The Plan says 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 
physical therapy by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system 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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, hyperlipidemia, chronic kidney disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation and NYSHA Class III congestive heart failure with mildly reduced LV ejection fraction (LVEF 40-45%) requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like to see this provider. The 
Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 
physician 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 the implant procedure (D6199). 
 
You asked the Plan to pre-approve the implant procedure (D6199). You say that the dentist said you cannot 
save the tooth. You say that tooth #19 needs to come out. The Plan denied your request. The Plan says the 
service 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 the 
implant procedure (D6199).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (E0218).
You asked the Plan to pre-approve the fluid circulating cold pad with pump. You say that you received a letter
stating that you have to have an illness to qualify for the machine. You would like to receive the arctic ice
machine that your doctor placed a referral for. The Plan denied your request. The Plan says this item is not
covered per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan
does not have to pre-approve fluid circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and partial lower denture (D5214).
You asked the Plan to pre-approve the complete upper denture (D5110) and partial lower denture (D5214). You say that the enrollee is not able to eat with the dentures and it is affecting his health. You say that the dentures need to be replaced. The Plan denied your request. The Plan says the services are limited to once every 5 years.
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 Plan also has a maximum benefit of one complete and partial denture every 5 plan years. The Plan paid for a complete upper denture provided on April 11, 2017 and a partial lower denture provided on July 26, 2017, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy and copayment for a 
specialist office visit provided by a participating provider on February 3, 2020 to February 13, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy and copayment for a specialist office visit. You 
say that you do not agree with these charges. The Plan denied your request. The Plan says the correct 
coinsurance and copayments have 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs/in-network/chemotherapy and a $35 copayment for 
physician/practitioner services/in-network/specialist.  
 
You have been asked to pay less than a 20% coinsurance of the allowed amount for chemotherapy and a $35 
copayment for a specialist office visit. The total amount you are being asked to pay is $2,605.92. 
Chemotherapy falls within the Medicare Part B prescription drugs/in-network/chemotherapy benefit category 
and a specialist office visit falls within the physician/practitioner services/in-network/specialist 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 coinsurance for chemotherapy and copayment for a specialist 
office visit provided by a participating provider on February 3, 2020 to February 13, 2020.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Life Alert Personal Emergency Response System 
(PERS). 
 
You asked the Plan to pre-approve the Life Alert. You say that you have a heart condition and you need a 
PERS. Your current PERS runs out on 7/15/2020. The Plan denied your request. The Plan says this item 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 Life Alert Personal Emergency Response System (PERS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system.. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested office visit. 
 
You asked the Plan to pre-approve the office visit. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested office visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services
You asked the Plan to pre-approve inpatient mental health services. You say that inpatient mental health care is
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health services. Our
reviewer says that the inpatient admission is not medically necessary. Our physician reviewer found the
admission of this enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee
was not shown to be actively a danger to himself or others and was without agitation or aggression. The
enrollee shows no perceptual disturbances including auditory, visual hallucinations or delusions.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health services
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay more for the crown provided on December 6, 2019. We decided that the 
Plan does not have to pay more for the remaining dental services.  
 
You asked the Plan to pay more for the dental services. You say that you have been going to this dentist for 
years and they never mentioned they were no longer in-network. The Plan says the claims processed correctly. 
 
We decided that the Plan has to pay more for the crown provided on December 6, 2019.  
 
The Plan is obligated to pay 50% of the allowed amount for the crown. The allowed amount for the crown is 
$452.50 (50% x $452.50 = $226.25). The Plan has only paid $169.30 toward the crown. Therefore, we decided 
that the Plan has to pay more for the crown provided on December 6, 2019.  
 
We also decided that the Plan does not have to pay more for the remaining dental services. 
 
The Plan is only obligated to pay 80% for covered basic dental services and 50% for covered major dental 
services. Any dental services not listed are not covered and you are responsible for the full amount. You are 
also responsible for the difference between the billed amount and allowed amount for services from an out-of-
network provider. This means that the remaining claims processed correctly. Therefore, we decided that the 
Plan does not have to pay more for the remaining dental services provided on November 15, 2019, January 16, 
2020 and March 4, 2020. 
 
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.