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

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with accessories.
You asked the Plan to pre-approve Group 2 power wheelchair with accessories. You say that the enrollee has fallen 3 times and needs this chair. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this power mobility device is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 2 power wheelchair with accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested power mobility device. Our physician reviewer found the documentation indicates that the enrollee has a mobility deficit that impairs mobility-related activities of daily living (MRADLs) in the home and is not ameliorated by a walker, cane, or manual wheelchair due to upper extremity weakness. While the enrollee may be able to safely operate a power mobility device, the requested Group 2 power wheelchair with multiple power options and accessories exceeds the enrollee's medical need. The documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, or utilized intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control power options through a joystick, as the enrollee's strength should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary.
Therefore, this requested power wheelchair with power options and accessories exceeds the enrollee's medical needs and is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 2 power wheelchair with accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Aspira drainage kits to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the Aspira drainage kits. You say that there are no in-network providers that
carry the Aspira brand. The Plan denied your request. The Plan says the provider is out-of-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 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
the Aspira drainage kits 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 pre-approve a comprehensive oral evaluation - new or established
patient (D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
You asked the Plan to pre-approve a comprehensive oral exam and tooth extraction. You say that you were
referred to the oral surgeon and it should be covered. The Plan denied your request. The Plan says these
services are not covered when provided by an oral surgeon.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a
comprehensive oral exam and tooth extraction when performed by a participating general dentist.
We looked at the file and Medicare rules. In this case you are requesting dental services to be performed by an oral surgeon. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral exam and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve
a comprehensive oral evaluation - new or established patient (D0150) and extraction, erupted tooth requiring
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have multiple sclerosis and drop foot. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial consultation to be rendered by the out of
network (OON) provider.
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 the
requested service.
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 service at issue in this appeal. We found no exception that would require the
Plan to pre-approve the service. Therefore, we decided that the Plan does not have to pre-approve an initial
consultation to be rendered by the out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion (E0190).
You asked the Plan to pre-approve the positioning cushion. You say that the cushion is medically necessary. The Plan denied your request. The Plan says this is not a covered 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 positioning cushion (E0190).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
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. Specifically, medically necessary services can be
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF)
admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the patient is medically stable for discharge and requires rehab and skilled nursing care. The Plan denied your request. The Plan says that the patient appears to be at her usual baseline of function and it would be unrealistic to expect her to return to a higher level of function in light of her recent stroke.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic appliance (E0667) and a
pneumatic compressor (E0651) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these items. 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 the
requested items.
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 at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the
Plan does not have to pre-approve a segmental pneumatic appliance (E0667) and a pneumatic compressor
(E0651) to be rendered by the out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical needs are too
complex for a lower level of care, and an LTACH is medically necessary. The Plan denied your request. The
Plan says the documentation does not show that the enrollee requires physician assessment daily or skilled
nursing services at least 6.5 hours a day. Criteria for an LTACH have not been met; the enrollee's needs can be
met at a lower level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be improving but requires only short-term additional acute
care services which can be safely administered at the current facility. The enrollee does not require services at
the LTACH that are not already available at the current facility. Therefore, this request for LTACH services
will be considered not medically reasonable and necessary at this time as there is no advantage to a transfer.
Transfer to another facility may be considered soon when appropriate and when treatments are completed.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns (D2740) for tooth #3 and tooth #19.
You asked the Plan to pre-approve the crowns. You say that the crowns are necessary. The Plan denied your request. The Plan says there is poor long-term prognosis for crowns on tooth #3 and tooth #19.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crowns. Our reviewer says that in general, teeth should have about 50% remaining bone to allow for proper support. Both tooth #3 and tooth #19 have less than 50% bone remaining and each does not have an opposing occlusion and therefore are not in function. The depth of the lesion on the distal of tooth #19 is of concern as it is approaching the level of the bone thus giving it a poor prognosis. Given the lack of proper bone support giving a poor crown to root ratio,
along with the lack of opposing dentition and lack of clear need for crown restoration of tooth #3 and poor prognosis of tooth #19 there is no medical necessity for the requested procedures.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve the crowns (D2740) for tooth #3 and tooth #19.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pain management consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the pain management consultation. You say that you do not want to continue to see your current doctor and would like to go out of network The Plan denied your request. The Plan says the provider is out-of-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 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 the pain management consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for an office visit with a specialist (99215) and a gelsyn-3 injection (J7328) provided on February 3, 2021.
You asked the Plan to waive the cost-share for an office visit and injection. You say that you received continuation of care after being diagnosed and hospitalized for Covid-19 in December of 2020. The Plan denied your request. The Plan says the cost-share 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 a 20% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $5 copayment for physician/practitioner services, including doctor's office and specialist visits.
You have been asked to pay a 20% coinsurance for injections and a $5 copayment for an office visit with a specialist. The allowed amount of the claim for the injection is $702.24, resulting in a coinsurance of $140.45. The EOC confirms that $5 is the required copayment for an office visit with a specialist. The total cost-share for these services is $145.45 ($140.45 + $5 = $145.45).
The records show that the appointment for this office visit and injection were requested prior to you being diagnosed and hospitalized for Covid-19. The records also show the provider did not code the claim indicating the visit was treatment for Covid-19. An office visit and injection fall within the Medicare Part B prescription drugs and physician/practitioner services, including doctor's office 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 cost-share for an office visit with a specialist (99215) and a gelsyn-3 injection (J7328) provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the oxygen concentrator and supplies provided on December 11, 2020.
You asked the Plan to pay for the oxygen concentrator and supplies. You say that you were not aware the provider was not in-network when the skilled nursing facility (SNF) ordered the oxygen supplies. The Plan denied your request. The Plan says that the provider is out-of-network.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the Explanation of Benefits which means we are unable to confirm if the Plan processed this claim correctly. Therefore, we decided that the Plan has to pay for the oxygen concentrator and supplies provided on December 11, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet joint injections.
You asked the Plan to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or
sacral; single level (64493), Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level
(List separately in addition to code for primary procedure) (64494), and Injection(s), diagnostic or therapeutic
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for
primary procedure) (64495). You say that the enrollee has sharp low back pain. The Plan denied your request.
The Plan says the records do not show the enrollee had 80% improvement in pain after the first injection.
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 injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this case, there was no documentation provided indicating 80% improvement or greater with
prior Medial Branch Blocks. According to the records the enrollee's pain went from a 7/10 to a 3/10. This is a
57% reduction in pain which is less than the 80% or greater required to meet the LCD criteria. The review has
determined that the requested repeat lumbar medial branch blocks are 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or
sacral; single level (64493), Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level
(List separately in addition to code for primary procedure) (64494), and Injection(s), diagnostic or therapeutic
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for
primary procedure) (64495) have not been met. Therefore, we decided that the Plan does not have to preapprove
repeat facet joint injections