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

We decided that the Plan does not have to pay for physical therapy provided by a physical therapy assistant on June 5, 2020.
You asked the Plan to pay for physical therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service provided.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy provided by a physical therapy assistant on June 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional trips.

You asked the Plan to pre-approve additional routine transportation. You say that you cannot drive for medical reasons. You also say that your need more trips get to your dialysis treatment 3 times per week. The Plan denied your request. The Plan says up to 24 one-way transportation trips per calendar year are covered. The Plan says that the Trip Record confirms that 21 trips have been requested or taken. The Plan says that there are 3 trips remaining. The Plan also says that additional routine transportation or mileage beyond the covered benefit allowance.

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 a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, additional routine transportation or mileage beyond the covered benefit allowance is not covered. Therefore, we decided that the Plan does not have to pre-approve 24 additional trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tempur-Pedic brand mattress and pillow.
You asked the Plan to pre-approve mattress and pillow. You say that this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because these items are not primarily medical in nature.
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 Tempur-Pedic brand mattress and pillow.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour (G0420) rendered by the out-of-network (OON) provider on November 6, 2019.

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 face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour (G0420) rendered by the out-of-network (OON) provider on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessory, high back solid seat (K0108) adapter plate, positioning component (K0108) assemble unit with transit (K0108).
You asked the Plan to pre-approve solid seat, adapter plate and transit loops. You say that you are requesting that this be re-reviewed for approval of the group 2 very heavy-duty power chair in place of the group 2 heavy duty. The Plan denied your request.
The Plan says these items are not considered to be primarily medical in nature and is therefore not covered by Medicare. A transit kit is only used for travel and not for use inside the home.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of solid seat, adapter plate and transit loops have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, high back solid seat (K0108) adapter plate, positioning component (K0108) assemble unit with transit (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve Tecentriq. You say that the requested Tecentriq is medically necessary. The Plan denied your request. The Plan says the requested Tecentriq is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Tecentriq. Our reviewer says that the requested Tecentriq is not medically necessary. Our physician reviewer found the enrollee is diagnosed with limited stage small cell lung cancer. The requested use of Tecentriq is not FDA-approved for the enrollee's diagnosis. The requested use of Tecentriq is not supported by any of the major compendia or by clinical research that appears in a CMS-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that for BRCA genetic testing to be covered, the individual being tested must have signs or symptoms of breast (invasive or ductal carcinoma in situ (DCIS), ovarian cancer (including fallopian tube and primary peritoneal cancer), pancreatic cancer, or prostate cancer. We looked at the file and Medicare rules. The file shows that you do not have a personal history of cancer for which BRCA testing is covered. 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 BRCA genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services as part of a phase II clinical trial.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the costs in a clinical trial are covered by Original Medicare.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve services as part of a phase II clinical trial.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation trip to go to your dialysis appointments and you currently to not have any other means of transportation. The Plan denied your request. The Plan says the requested additional transportation trips go beyond the allowed benefit in the subscriber agreement.
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 a maximum of 24 one-way trips per year. 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services.
You asked the Plan to pre-approve the acupuncture services. You say that you have been having severe back pain in the middle and upper region for 5 years. You have tried physical therapy, creams and ointments, been to dermatologist and neurologists. The pain continues and the itching gets worse. The Plan denied your request. The Plan says you do not meet the criteria as you do not have chronic lower back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture is covered for members with chronic low back pain. You do not meet the criteria as you do not have chronic lower back pain. Therefore, we decided that the Plan does not have to pre-approve the acupuncture services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix 10mg tablet 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 the requested drug is intended 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 Trintellix 10mg tablet for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9945).

You asked the Plan to pre-approve the dental item. You say that you grind your teeth at night. You say that as a result your gums are inflamed, and you experience pain when you chew food. You also say that you cannot afford to pay for this dental item. The Plan denied your request. The Plan says occlusal guard is not listed as a covered dental item.

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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide therapeutic continuous glucose monitor sensors.
You asked the Plan to provide therapeutic continuous glucose monitor sensors. You say that the enrollee needs CGM sensors. The Plan denied your request. The Plan says the enrollee does not require insulin shots multiple times per day and therefore does not meet the coverage criteria.
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 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 therapeutic continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to provide therapeutic continuous glucose monitor sensors
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that massage therapy has been recommended by your primary care physician, neurosurgeon and physical therapists for your unique situation. You say that you haven't found a facility that has both massage and physical therapy, and you cannot afford to pay for a licensed massage therapist. The Plan denied your request. The Plan says massage is only covered if offered as part of a physical therapy program.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Tempur-Pedic, Tempur Supreme mattress topper (E1399).
You asked the Plan to pre-approve the Tempur-Pedic mattress topper. You say that your doctor has persistently ordered a Temper-Pedic mattress topper, and you would like to appeal. The Plan denied your request. The Plan says this is a convenience item and there are covered items that can meet your medical needs.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Tempur-Pedic mattress topper have not been met. Therefore, we decided that the Plan does not have to pre-approve the Tempur-Pedic, Tempur Supreme mattress topper (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) screening colonography (74263).

You asked the Plan to pre-approve a CT screening colonography. You say that this should be covered. The Plan denied your request. The Plan says this is not listed as a covered screening service.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a CT screening colonography, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic (CT) screening colonography (74263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260 x4).

You asked the Plan to pre-approve the osseous surgery. You say that the requested service is necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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. 

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 the osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260 x4).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria.

You asked the Plan to pre-approve Simponi Aria. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Simponi Aria is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Simponi Aria. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 39-year-old female with Reiter's disease. In this case, Simponi Aria is not FDA-approved for the enrollee's condition. According to the currently available evidence found in the approved compendia, there is insufficient evidence to support the use of Simponi Aria for Reiter's disease.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria.
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 you need new dentures as your current set is broken. The Plan denied your request. The Plan says dentures can only be covered once every five years. The Plan previously paid for dentures for you in October of 2018. It has been less than five years from when you previously received dentures, and the services cannot be pre-approved.
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 can cover one set of dentures every five years. Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that is not covered under this benefit. Documentation shows that the Plan paid for dentures for you in 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device (22869, 22870).
You asked the Plan to pre-approve the Vertiflex device. You say that you request a review for the denial for the posterior interspinous decompression spacer procedure to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says this device unproven, experimental and/or investigation and is still being studied to determine safety and efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a massage chair.
You asked the Plan to pre-approve a massage chair. You say that you need this because you are always in pain. The Plan denied your request. The Plan says this is not a medical 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 massage chair
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroilaic joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental/investigational due to the wide variation in efficacy reported in the literature. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroilaic joint radiofrequency ablation for the enrollee.