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

We decided that the Plan does not have to pre-approve a crown, post and core in addition to crown, three
periodontal scalings and root planings, maxillary partial denture, and maxillary interim partial denture.

You asked the Plan to pre-approve the crown, post and core, scalings and planings, maxillary partial denture,
and maxillary interim partial denture. You say that the deep cleaning is needed. The Plan denied your request.
The Plan says the crown, post and core, and scaling and planing are not covered benefits. The Plan also says
that you have exceeded the maximum count allowed per period for maxillary dentures.

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, crown, post and core in addition to
crown, and periodontal scaling and root planing are not among those covered under this benefit. The Plan
contract also says that complete or partial dentures are covered once every five years. The record shows that
you received a maxillary partial denture on May 30, 2019, and your maxillary denture benefit has been
exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown, post and core in addition
to crown, three periodontal scalings and root planings, maxillary partial denture, and maxillary interim partial
denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that the enrollee has mobility issues. The Plan denied
your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee.

You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a corrected claim will need to be billed with a valid Health Insurance Prospective Payment System (HIPPS) code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve outpatient mental health services. You say that you feel comfortable with this provider. The Plan denied your request. The Plan says there are in-network providers who can provide these services safely.

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 outpatient mental health services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day monitoring system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says blood glucose is not being checked four times daily.

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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has been making frequent adjustments to his insulin regimen on the basis of testing results and has been using a blood glucose monitor with frequent (four or more times a day) testing. 

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day monitoring system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient hospital care.

You asked the Plan to pre-approve inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient hospital care. Our reviewer says that inpatient hospital care is not medically reasonable and necessary. In this case, the record does not indicate that you have any co-morbidities that would reasonably result in the expectation that you would require more than a two-day stay. In addition, the attending physician has not indicated that he expects a medical requirement for the more than two-day stay. Therefore, you can initially be managed in observation status. The record does not support that the admitting physician reasonably expected that your necessary hospital care would span two midnights and therefore the inpatient stay is not recommended. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stair glide repairs.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

A stair glide does not serve a purpose that is primarily medical in nature and is not covered by Medicare. Repairs to this item are also non-covered. Therefore, we decided that the Plan does not have to pre-approve stair glide repairs.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (29826) provided July 16, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid primary code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 29826 is not supported in the medical record. Specifically, the CPT code billed is considered an add-on code. There was no valid code billed as a primary procedure. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (29826) provided July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures (D5110, D5120).

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

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 dentures once every five years. Dentures were last received less than five years ago. 

Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve dentures (D5110, D5120).
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 this service has been covered. The Plan denied your request. The Plan says this item is 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high-intensity focused ultrasound for the enrollee.

You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 ultrasound. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found specifically, whole gland high-intensity focused ultrasound is considered medically necessary as a local treatment for recurrent PCa following radiation therapy (RT). The records provided show that this enrollee has not received radiation therapy (RT). 

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 ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve a high-intensity focused ultrasound for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the K3 level prosthesis and protective covering (L5962).

You asked the Plan to pre-approve the prosthesis and related supplies. You say that the enrollee's needs are that of a K3 ambulator. The Plan denied your request. The Plan says the request for a K3 prosthesis exceeds member's need and does not meet Medicare criteria as reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that certain criteria must be met for a plan to cover a K3 prosthesis. 

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 prosthesis and related supplies. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no objective clinical documentation from the physician to corroborate the vendor's claim that member requires a K3 foot. As noted, notes indicate that member is using a cane and is expected to continue to require use of a cane. This is inconsistent with K3 ambulation. 

Per Medicare guidelines, "Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary." The prosthetist is the vendor and therefore has financial interest in the outcome of the claim. Signed physician order includes K3 foot. 

Per Medicare rules, "A prescription is not considered to be part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. 

Request for K3 prosthesis exceeds member's need and does not meet Medicare criteria as reasonable and necessary. There is no documentation of unusually harsh environmental situations for which a specialized lower limb prosthetic cover (L5962) is required and for which a standard prosthetic cover (L5704) would be insufficient. The enrollee does not meet coverage criteria for the protective outer surface covering system. 

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 prosthesis and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the K3 level prosthesis and protective covering (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve block.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this type of injection is considered experimental and investigational.

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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this would be considered an experimental/ investigational procedure as there are no clinical trials that supports its use in rotator cuff tears or other shoulder pathology. Therefore, the request is considered not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a urologist.

You asked the Plan to pre-approve the referral. You say that this provider has your medical history and records. The Plan denied your request. The Plan says this provider has your medical history and records.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found in-network providers (urologists) are available that can perform these procedures. 

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to a urologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6740, D6245).

You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's dental benefit has been exhausted.

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 enrollee's dental benefit has been exhausted. The plan covers up to $1,500 a year. The plan has already paid for $1,500 in dental services. Therefore, we decided that the Plan does not have to pre-approve dental services (D6740, D6245).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.

You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Botox for the enrollee.

Benefits for Botox 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network provider.

You asked the Plan to pre-approve the ophthalmology services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available that can provide this service.

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 ophthalmology services to be provided by an 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 for the enrollee.

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 the enrollee can safely receive the services needed 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 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 for the enrollee.