Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to approve six physical therapy (PT) visits.

You asked the Plan to approve these services. You say that you need more PT prior to surgery. 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 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 approve these services. 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 the records do not support that the requested therapy is generally accepted as specific and effective therapy for your condition. You have met your maximum functional level with therapy. Further therapy beyond the approved services would not likely achieve any significant improvement in your symptoms or functional status. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. Six further visits are not reasonable or medically necessary to maintain your current condition or prevent/slow further 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 these services have not been met. Therefore, we decided that the Plan does not have to approve six physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
You asked the Plan to pre-approve the dentures. You say that your current dentures do not fit anymore, and you have had more teeth pulled. New dentures are necessary. The Plan denied your request. The Plan says coverage was already approved and payment was estimated for the tooth extractions and a full set of immediate dentures. However, the provider requested a second set of dentures to replace the immediate dentures if it was found necessary after the extractions healed. Your dental benefit can only cover replacement dentures after five years from the previous set. Therefore, the upper and lower dentures to replace the initial immediate set cannot be covered.
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 requested in a frequency greater than what is allowed under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee cannot self-test. The Plan denied your request. The Plan says criteria is not met 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 or uses insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99213) to be rendered by the out-of-network (OON) provider at an in-network rate.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render this requested service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that that as a member of the Plan, you can receive your care from either a network provider or an out-of-network provider. If you use an out-of-network provider, your share of the costs for your covered services may be higher. Additionally, if there isn't a network provider within your plan service area available for you to see, you can go to an out-of-network provider but still pay the in-network amounts. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available within the service area who can provide the service at issue in this appeal. The Plan contract states that if you use an out-of-network provider, your share of the costs for your covered services may be higher. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit (99213) to be rendered by the out-of-network (OON) provider at an in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223), therapeutic parenteral drugs (D9612), and reduction of osseous tuberosity (D7485 x 2).
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says deep sedation is not listed as a covered service. The Plan says that therapeutic parenteral drug is not listed as a covered service. The Plan also says that reduction of osseous tuberosity is not listed as a covered service either.
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 an initial 15 minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223), therapeutic parenteral drugs (D9612), and reduction of osseous tuberosity (D7485 x 2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrointestinal tract imaging (capsule endoscopy) (91110) provided on November 17, 2020.
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 that a capsule endoscopy is only payable for those beneficiaries who have undergone an upper gastrointestinal endoscopy and colonoscopy, within the same episode of illness, that have failed to reveal a source of bleeding.
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 pay for this service. Our reviewer says that the service provided is not considered medically reasonable and necessary in this case. Our physician reviewer found that the capsule endoscopy was performed for the indication of iron deficiency anemia. The study was interpreted as normal. The records do not support that the enrollee had anemia or gastrointestinal blood loss at the time of testing, nor that the Esophagogastroduodenoscopy (EGD) and colonoscopy had failed to identify a source of iron deficiency prior to the capsule endoscopy study. The provided documents do not support the indications for coverage and do not demonstrate the medical appropriateness and safety of the study in the enrollee's specific 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 this service have not been met. Therefore, we decided that the Plan does not have to pay for the gastrointestinal tract imaging (capsule endoscopy) (91110) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve a sleep study. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there is no clinical rationale for the requested sleep study. There is no documentation of any signs/symptoms of obstructive sleep apnea. The review has determined that the requested sleep study is not medically necessary or reasonable. 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided by Fountain Orthotics.

You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided by Fountain Orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are medically necessary and should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 acupuncture services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a labial veneer (D2962) for tooth # 9.
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied your request. The Plan says labial veneer 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 labial veneer (D2962) for tooth # 9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that you would like reconsideration because the member would benefit from a continuous glucose monitor. The Plan denied your request. The Plan says the member does not use insulin or an insulin pump.

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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic imaging to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve diagnostic imaging. You say that you would like these services approved. The Plan denied your request. The Plan says these services are not medically necessary.
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 diagnostic imaging to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services with dental codes D0220, D0230, D2740, and D2920 provided on November 12, 2020.
You asked the Plan to pay additionally for dental codes D0220, D0230, D2740, and D2920. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the dental claims processed correctly.
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, the Plan's contract and Medicare rules. The file shows the provider billed service D0220 in the amount of $24. The allowed amount for the service is $13. The Plan pays 100% of the allowable amount per the benefits outlined in the Evidence of Coverage (EOC). The Plan paid $13. You are responsible for all fees billed by the provider in excess of the allowed amount $11 ($24-$13). Your liability for dental code D0220 is $11. The file shows the provider billed service D0230 in the amount of $21. The Plan pays 100% of the allowable amount per the benefits outlined in the EOC. The Plan paid $9. You are responsible for all fees billed by the provider in excess of the allowed amount $12 ($21-$9). Your liability for dental code D0230 is $12. The file shows the provider billed service D2740 in the amount of $1050. The Plan pays 50% of the allowable amount per the benefits outlined in the EOC. The Plan paid $305. Your liability for dental code D27410 is $750. The file shows the provider billed service D2920 in the amount of $91. The Plan pays 50% of the allowable amount per the benefits outlined in the EOC. The Plan paid $23.50. Your liability for dental code D2920 is
$67.50. Therefore, we decided that the Plan does not have to pay additionally for the dental services with dental codes D0220, D0230, D2740, and D2920 provided on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the surgical services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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. 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 surgical services provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

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 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on April 13, 2021 with respiratory failure due to COVID-19. On April 19, 2021 she walked eight feet with assistance. She needs assistance with bed mobility and transfers. She is medically stable. She has no complex wound care or other skilled nursing needs. She has skilled therapy but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery, allograft for spine surgery only (20930) arthrodesis (22551, 22552) anterior instrumentation (22845) insertion of biomechanical device (22853).
You asked the Plan to pre-approve the spinal surgery. You say that based on the information provided, this is medically appropriate and necessary for the enrollee. You respectfully request review of the additional documentation provided and consider overturning. The Plan denied your request. The Plan says the requested surgery is not considered medically necessary at this time.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the is no documentation of cervical instability, fracture or lesion. There is no documentation of severe neurologic deficit. There is no documentation of severe cord compression. Criteria for cervical surgery not met. 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery, allograft for spine surgery only (20930) arthrodesis (22551, 22552) anterior instrumentation (22845) insertion of biomechanical device (22853).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 microprocessor and volume management system for a prosthesis.
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. Medicare rules say that prosthesis accessories are covered when specific criteria are met. 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 requested items exceed the enrollee's medical need. The physician documentation does not support that he is a level K3 ambulator, given the documentation that he used a walker prior to amputation due to back pain. Furthermore, the physician documentation does not support that the patient requires a volume management system and this also exceeds the enrollee's medical need and is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 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 K3 microprocessor and volume management system for a prosthesis.