Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a replacement continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that you are not compliant with the current device.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the monitor. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you take three shots a day of insulin. The new system that is being requested is appropriate because you have poor vision, and have trouble seeing the blood glucose level on the screen. The alert is useful, and medically necessary for you. 

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 monitor have been met. Therefore, we decided that the Plan has to pre-approve a replacement continuous glucose monitor.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pathology procedure (88112) provided on April 26, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pathology procedure. You say that the services were medically necessary. The 
Plan denied your request. The Plan says services were provided by an out-of-network provider without prior 
authorization. We decided that the Plan does not have to pay for a pathology procedure (88112) provided on April 26, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pathology procedure. You say that the services were medically necessary. The 
Plan denied your request. The Plan says services were provided by an out-of-network provider without prior 
authorization.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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. The records provided for review do not show that the services at issue were urgent or 
emergent. 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 a pathology procedure (88112) provided on April 26, 2021, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), and an extraction (D7140) provided from March 22, 2021, through April 7, 2021.

You asked the Plan to pay an additional amount for a limited oral evaluation, an intraoral periapical radiographic image, and an extraction. You say that these services were necessary. The Plan denied your request. The Plan says the limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every Plan year. The intraoral periapical radiographic image, and extraction are covered benefits, however the benefit maximum had already 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, an intraoral periapical radiographic image, and an extraction have not been met. Specifically, the record shows that you had exceeded the frequency limit for the limited oral evaluation prior to this service on January 26, 2021. Additionally, the intraoral periapical radiographic image, and extraction are covered benefits, however you had exhausted your dental benefit maximum. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), and an extraction (D7140) provided from March 22, 2021, through April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. 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 facet joint injections. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that degenerative disc disease was demonstrated at L4-L5 with disc bulge and facet
hypertrophy resulting in moderate spinal canal stenosis. Mild left-sided neural foraminal stenosis was present at
L5-S1 with no significant disc herniation. The documentation does not support that the lumbosacral facet
injections are needed at all of the requested levels.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intraoral periapical radiographic image (D0230), and localized delivery of antimicrobial agents (D4381) provided on January 28, 2021.

You asked the Plan to pre-approve an intraoral periapical radiographic image, and localized delivery of antimicrobial agents. You say that you thought these services would be covered. The Plan denied your request. The Plan says the intraoral periapical radiographic image is a covered benefit, but you have exceeded the frequency limit of one every calendar year. Localized delivery of antimicrobial agents 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image, and localized delivery of antimicrobial agents have not been met. Specifically, the record shows that you had exceeded the frequency limit for an intraoral periapical radiographic image. Additionally, localized delivery of antimicrobial agents is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve an intraoral periapical radiographic image (D0230), and localized delivery of antimicrobial agents (D4381) provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on February 12, 2021.

You asked the Plan to pay for a crown, and a core buildup. You say that you want the Plan to consider paying for the services under your medical Plan because they are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.

Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Spinal Q TSO back orthosis.

You asked the Plan to pre-approve back orthosis. You say that you have tried everything the Plan has told you with very little results and think the Plan should help you with the cost of this brace. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this item is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments are not covered by Medicare. 

We looked at the file and Medicare rules. The requested Spinal Q TSO is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of back orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a Spinal Q TSO back orthosis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services. The medical records provided show this enrollee does require skilled therapy services; however, daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower 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: Favorable

We decided that the Plan has to pre-approve the diabetic shoes (A5500) and six diabetics only, multiple density inserts (A5512).

You asked the Plan to pre-approve the diabetic shoes and inserts. You say that you are appealing the denial for coverage for 1 pair of diabetic shoes (A5500) and 3 pairs of heat moldable inserts (A5512). The Plan denied your request. The Plan says that the records do not support that the enrollee meets the Medicare criteria as the specific documentation of the foot deformity by the certifying clinician has not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the diabetic shoes and inserts. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found It is well established in the progress note dated 6/23/2021 that this enrollee suffers with diabetes. The enrollee is noted to have neuropathy (loss of protective sensation) as well as a musculoskeletal deformity (hammertoe contractures digits 2 - 5). These findings support the necessity for diabetic shoes and insoles. Specifically, the guidelines advise that a beneficiary must have diabetes and at the very least a foot deformity of either foot. The medical documentation dated 6/23/2021 does support that this patient has diabetes with a musculoskeletal deformity. Therefore, the requested diabetic shoes and diabetic insoles are medically reasonable and 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 diabetic shoes and inserts have been met. Therefore, we decided that the Plan has to pre-approve the diabetic shoes (A5500) and six diabetics only, multiple density inserts (A5512).

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid or have a history of osteoporotic fracture.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The Plan requires a trial of zoledronic acid or have a history of osteoporotic fracture before they will approve the requested drug. The case file does not contain documentation of trial and failure of zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received at your 
doctor's office on November 5, 2020. 
 
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you do not believe it is fair 
to charge this coinsurance just because you got this drug at your doctor's office.  If you had picked up the drug 
at the pharmacy, you wouldn't have had cost sharing because you claim you had already met your annual 
deductible. The Plan denied your request. The Plan says you were charged this coinsurance correctly. 
 
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 20% 
coinsurance for Medicare Part B drugs you receive at a doctor's office.  
 
You have been asked to pay 20% coinsurance for the Prolia injection. Your Evidence of Coverage explicitly 
says that if you get drugs in your doctor's office, you are responsible for 20% coinsurance. 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 the Prolia injection you received at your doctor's office on 
November 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require any skilled nursing services and they do not require skilled therapy services on a daily basis or at an inpatient level in a SNF. 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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (43239) provided on December 11, 2020.
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you would like reconsideration because you were told this service would be free. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for outpatient surgery. You have been asked to pay a $325 copayment for the esophagogastroduodenoscopy. The esophagogastroduodenoscopy falls within the outpatient surgery benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (43239) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99348) rendered by the out-of-network (OON) provider on February 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99348) rendered by the out-of-network (OON) provider on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your 
request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective; 
therefore, it is not considered "standard of care." 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion 
interspinous device is 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee