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

We decided that the Plan does not have to pay for the preventive procedure.

You asked the Plan to pay for the preventive procedure. You say that the provider contacted the Plan and was advised that they were in-network. The Plan denied your request. The Plan says this service is not a covered expense under your plan.

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 pay for the preventive procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic images and panoramic x-ray.

You asked the Plan to pay for the 2D oral/facial photographic images and panoramic x-ray. You say that a Plan representative referred you to this treating provider. You also say that you were under the impression that the provider's office had gotten approval to treat you. The Plan denied your request. The Plan says 2D oral/facial photographic image is not a covered benefit. The Plan also says that benefits for the panoramic x-ray have been satisfied and the frequency limitation has been exceeded.

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, 2D oral/facial photographic image is not among those covered under this benefit. The Plan contract includes coverage for full mouth or panoramic x-rays and are limited to one procedure every five years. The record shows that you received a complete series of intraoral x-rays, and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic images and panoramic x-ray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain/ceramic crowns for teeth #14 and #15.

You asked the Plan to pre-approve porcelain/ceramic crowns. You say that this service is medically necessary
and reasonable. The Plan denied your request. The Plan says criteria for crown services have not been met.

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
porcelain/ceramic crowns when the services are medically necessary and reasonable.

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 porcelain/ceramic crowns. Our
reviewer says that the requested crowns are not medically necessary. Our physician reviewer found the
documentation provided does not show significant coronal breakdown requiring crown restorations for the
requested teeth.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of porcelain/ceramic crowns have not been met. Therefore, we decided that the
Plan does not have to pre-approve porcelain/ceramic crowns for teeth #14 and #15.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee's failed discharge home after a full stay
at a skilled nursing facility is evidence that his condition cannot be appropriately managed at any facility that
does not offer a hospital level of care. The Plan denied your request. The Plan says the denial of authorization
for IRF service is correct.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record
documents a need for physical and occupational therapies, but not for an intensive rehabilitation therapy
program. Medically necessary services could be provided in a lower level of care. There is not a reasonable
expectation that this enrollee will be able to fully participate in, and benefit from, the intensive rehabilitation
therapy program provided in an IRF.

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 a Group 3 power wheelchair with multiple power options (K0861) with accessories.

You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the requested items are needed for your activities of daily living. The Plan denied your request. The Plan says rules for pre-approval of a Group 3 power wheelchair with multiple power options have not been met.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair with multiple power options can be covered only for enrollees who meet coverage criteria for a power tilt and recline seating system or who use a ventilator which is mounted on the wheelchair.

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 Group 3 power wheelchair. Our reviewer says that a Group 3 power wheelchair (K0861) with multiple power options is not medically necessary. Our physician reviewer found that you have a personal mobility deficit that impairs participation in MRADLs. The documentation states that you do not have functional balance, strength, or endurance to safely and independently use a cane, walker, or crutch and cannot use a manual wheelchair due to right upper extremity hemiparesis. You are noted to be able to safely operate the requested PMD. You have hemiparesis from a stroke and therefore have a covered indication that would require a Group 3 power wheelchair as specified in the Medicare rules. However, you are not at high risk for development of a pressure ulcer. You do not utilize intermittent catheterization for bladder management and do not need the power seating system to manage increased tone or spasticity. The power seating system is not medically necessary. The request for a Group 3 wheelchair with multiple power options is not medically necessary and therefore all related accessories are not 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 a Group 3 power wheelchair with multiple power options have not been met. Because the base wheelchair has been judged to be not medically necessary, the related accessories are also not medically necessary. Medicare rules for coverage of the related accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) with accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sodium bicarbonate.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has gastroparesis. The diagnosis of "other fatigue" provided by the physician is not a medically accepted use for sodium bicarbonate. The records do not support that the requested drug is safe and effective or reasonable and medically necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve sodium bicarbonate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a mobility limitation that interferes with the completion of mobility-related activities of daily living (MRADLs) in the home. The mobility limitation is unable to be helped by a cane/walker or walker due to safety and dyspnea with exertion. He does not meet the coverage criteria for a power tilt and recline seating system, as he is able to perform functional weight shifts. He does not use intermittent catheterization for bladder management or a ventilator. The power seating system is not needed to manage increased tone or spasticity. He does not have a knee brace or cast on the legs or leg edema; therefore, the elevating leg rests are not needed. The requested services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab testing services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that there is no documentation of immunodeficiency.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The file shows that the testing services at issue were provided with a diagnosis of diarrhea. We looked at the file and the rules. GIP panels utilizing NAATs are medically reasonable and necessary for the evaluation of Medicare beneficiaries with acute or persistent diarrhea.

Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the lab testing services.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued.

You asked the Plan to pay for the compression stockings. You say that the item should be covered. The Plan denied your request. The Plan says the item is an excluded benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (Dexcom G6).

You asked the Plan to pre-approve continuous glucose monitor. You say that you feel you will get a better
reading and less pain by using this device. The Plan denied your request. The Plan says the denial of
authorization for this item is correct, because you do not meet the Medicare criteria for a therapeutic
continuous glucose monitor.

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, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we
decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (Dexcom G6).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because
the member has dementia and is disoriented. The Plan denied your request. The Plan says Medicare does not
cover custodial care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says Medicare guidelines for admission to inpatient rehabilitation have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medial necessary services could be provided in a low level of care. There is a not reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is dispensed for patient self-administration.

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 Prolia for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that it is the facility's responsibility to obtain the authorization, and the doctor should not be penalized for their inaction. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that there was not a valid authorization on file.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed.

You asked the Plan to pay for a hospital bed. You say that due to Covid-19, you were unable to go through a Plan provider. The Plan denied your request. The Plan says you purchased the durable medical equipment and received non-covered, explicitly excluded items, from a non-certified provider; therefore, the DME is not covered by the plan. You are responsible for the full cost of the durable medical equipment.

The Plan must follow Medicare rules. The rules say that you must receive services from a provider or DME supplier enrolled in the Medicare program. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hospital bed have not been met. Specifically, you did not receive the hospital bed from a supplier enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64495 and 64494).

You asked the Plan to pre-approve the facet joint injections. You say that the records provided should support
the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee does not meet
medical necessity requirements.

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 facet joint injections. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has chronic low back pain. She is taking ibuprofen for pain and has had
an Epidural Steroid injection that provided relief for only 3 days. Imaging shows a disc abutting the left-L3
nerve root as well as spinal stenosis and facet arthropathy. The enrollee has not had a surgical consultation. The
enrollee has another clear pain generator and therefore, does not meet the LCD 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 the facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections (64493, 64495 and 64494).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.

You asked the Plan to pre-approve SNF care. You say that the requested services are medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs or identifiable skilled therapy service needs. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services.