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

We decided that the Plan does not have to pre-approve at a lower cost sharethe upper and lower dentures.You asked the Plan to pre-approve at a lower cost sharethe upper and lower dentures. You say that you would like this claim approved at a lower cost share.The Plan denied your request. The Plan says copayments are a fixed amount that you are responsible for and cannot be waived or reduced.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.You have been asked to pay a 50% coinsurance for the upper and lower dentures. These services fall within the Class 3 Major Services benefit category for the Plan's supplemental dental rider. This cost share cannot be waived as it is based on the contract with your Plan.Therefore, we decided that the Plan does not have to pre-approve at a lower cost sharethe upper and lower dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SoClean CPAP cleaner and sanitizing machine.
You asked the Plan to pre-approve SoClean CPAP cleaner and sanitizing machine. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a
covered benefit.
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. In addition, this
item is over-the-counter and does not require a prescription to obtain. Therefore, we decided that the Plan does
not have to pre-approve SoClean CPAP cleaner and sanitizing machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve a power scooter. You say that you need the scooter to use when you go to the store if your car breaks down.The Plan denied your request. The Plan says that you do not meet criteria for coverage.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth #12.
You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan
denied your request. The Plan says porcelain crown is not listed as a covered service.
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 a
porcelain crown (D2740) for tooth #12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power mobility device.
You asked the Plan to pre-approve the seat elevation feature. You say that the accessory is medically necessary. The Plan denied your request. The Plan says this feature is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered. We looked at the file and Medicare rules. The requested feature is non-covered. Based on this information, we decided that Medicare rules for coverage of the seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepodiatry services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvepodiatry services. You say that you would like a follow-up visit with this provider. You say that you have seen this provider in the past.The Plan denied your request. The Plan says there are in-network providers available.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 incases 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-approvepodiatry services to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that HBOT is covered for specific indications only.
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 medically necessary. Our physician reviewer found the enrollee has non-healing wounds with
arterial and venous insufficiency. The nature, ongoing therapy, and severity of these lesions make HBO therapy
medically reasonable and appropriate and risk of limb loss is noted. The services are medically necessary at
this time.
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 been met. Therefore, we decided that the Plan has to preapprove
hyperbaric oxygen therapy (HBOT).
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 forthe orthoses as defined by codes L0650, L1971, L3170, L3960 on July 23, 2020You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted.The Plan must follow Medicarerules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The proof of delivery did not contain the order number, and the medical records did not support sufficient evidence of necessity or an in person evaluation, or appropriate use of telehealth in this case.  The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe orthoses as defined by codes L0650, L1971, L3170, L3960 on July 23, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a light box (E0203).
You asked the Plan to pre-approve the light box. You say that the light box is medically necessary. The Plan
denied your request. The Plan says this item is not considered a covered DME item.
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 a light box (E0203).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane. 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 right hip, buttock, and
knee pain following a remote fall. It is unclear how much of the knee pain is related to radiculopathy versus primary knee pathology. X-rays of the knee do not show significant arthritic changes. There is no evidence that the enrollee has tried oral medications or steroid injections, or how the enrollee responded to these treatments. Physical therapy has resulted in improvement of knee motion and strength. The Durolane is not reasonable or medically necessary at this time. 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 Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the semi-electric bed 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 a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the requested bed is not medically necessary. Our physician reviewer found there is no indication in the records that the enrollee requires frequent changes in body position or a need for immediate changes in body position.
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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehome health services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonableor necessary. Our physician reviewer found the documentation does not show physician or treating medical practitioner medical records that indicate skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy is needed to effectively provide treatment, care, and/or servicesin order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehome health services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspirate.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the spinal fusion is approved but bone marrow aspirate 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 ourphysician 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 back and neck pain. The requested bone marrow aspirate is experimental in nature, as more research is needed to show its safety and efficacy. The services are therefore not reasonable or medically necessary.We lookedat 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-approvebone marrow aspirate.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional speech therapy visits for a total of 12 speech therapy visits.You asked the Plan to pre-approveadditional speech therapy visits. You say that these services are medically necessary.The Plan denied your request. The Plan says the member does not meet the guidelines for coverage of this service,and it is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 additional speech therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found it does not appear that the patient requires additional therapy beyond what was approved by the health plan with the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. In addition, the patient's memory deficits would limit carryover and her swallowing and care plan can be supervised and carried out by staff at her facility and caregivers. We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of additional speech therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve4 additional speech therapy visits for a total of 12 speech therapy visits.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve acomputed tomography, abdomen; without contrast material (CT scan) (74150).

You asked the Plan to pre-approve aCT scan. You say that the service is medically necessary.

The Plan denied your request. The Plan says that the service is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT scan. Our reviewer says that the service is medically necessary. Our physician reviewer found that the available records indicate the scan has been ordered to evaluate the enrollee's renal stones (in addition to the cancer diagnosis). Although the scan for surveillance for cancer is not indicated the renal stone diagnosis is an acceptable indication for the scan.

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 CT scan have been met. Specifically, we found that the CT scan is medically necessary.Therefore, we decided that the Plan has to pre-approve acomputed tomography, abdomen; without contrast material (CT scan) (74150)

.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve the services. You say that this is medically necessary to attend
appointments. The Plan denied your request. The Plan says the service is a covered benefit, but the request
exceeds the mileage limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation up to 75 miles one-way each trip.
We looked at your request, the records in the case file, and the rules. You cannot request more mileage than 75
miles one-way for each trip. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional
routine transportation mileage.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you need long-term care.The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you are current at an inpatient rehabilitation facility after a stroke. You have stable vital signs and received physical, speech, and occupational therapy. You need varied levels of assistance with activities of daily living. You have no skilled therapy needs. You have skilled nursing needs but do not require skilled nursing on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for respiratory failure, chronic obstructive pulmonary disease (COPD) exacerbation, and COVID-19
infection. Her medical conditions are stable with no complex nursing or rehabilitation needs. She does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that the 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 waive the coinsurance fordiabetic foot orthotics provided on February 18, 2020.You asked the Plan to waive the coinsurance fordiabetic foot orthotics. You say that these shoes are a poor fit for you.The Plan denied your request. The Plan says the coinsurance 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 5% coinsurance for in-network diabetic foot orthotics. The allowed amount of the claim is $328.52, resulting in a coinsurance obligation of $16.43.You have been asked to pay 5% coinsurance for diabetic foot orthotics. Diabetic foot orthotics fall within the Diabetes Self-Management Training, Diabetic Services and Supplies 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 fordiabetic foot orthotics provided on February 18, 2020