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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are aware that the chronic lymphedema does not currently extend to the trunk and/or chest area. However, this enrollee has been diagnosed for several years with no relief provided this far. The Plan denied your request. The Plan says the enrollee does not meet the criteria as they do not have lymphedema extending into the chest, trunk or abdomen.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist splint provided on May 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a wrist splint. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for this equipment.
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 a wrist splint provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (D3310) and comprehensive oral evaluation - new or established patient (D0150) to be performed by an endodontist.

You asked the Plan to pre-approve root canals and a comprehensive oral exam performed by an endodontist. You say that you are in pain and the services are necessary. The Plan denied your request. The Plan says that these services are not covered because they are requested to be performed by an endodontist.

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 certain dental services when performed by an endodontist. 

We looked at the file and Medicare rules. In this case the services at issue are requested to be performed by an endodontist. Based on this information, we decided that the Plan's rules for coverage of root canals and a comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration) (D3310) and comprehensive oral evaluation - new or established patient (D0150) to be performed by an endodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a room air purifier.

You asked the Plan to pre-approve the purifier. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 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 room air purifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (87210) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on May 7, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory service (87210) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on May 7, 2021.
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 IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 based on the records, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a OneTouch Ultra2 blood glucose monitor (E0607).
You asked the Plan to pre-approve a OneTouch Ultra2 blood glucose monitor. You say that this should be covered. The Plan denied your request. The Plan says this is not a preferred brand.
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only those preferred brands and manufacturers. We looked at the file and Medicare rules. The requested blood glucose monitor is not from the Plan's preferred brands. The submitted medical records do not document any reasoning for why the enrollee's needs cannot be met with a preferred brand of glucose monitor. Based on this information, we decided that Medicare rules for coverage of a OneTouch Ultra2 blood glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a OneTouch Ultra2 blood glucose monitor (E0607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve push handles for the enrollee.
You asked the Plan to pre-approve the handles. You say that this is medically necessary. The Plan denied your request. The Plan says upgraded handles are not considered medically necessary.
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 push handles for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that this is medically
necessary for the enrollee. The Plan denied your request. The Plan says that this has been denied because it is
not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve
a power seat elevation feature (E2300) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic services provided on April 8, 2021, to April 14, 2021, by an OON provider.
You asked the Plan to pay for outpatient clinic services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services.
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 outpatient clinic services provided on April 8,
2021, to April 14, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273).
You asked the Plan to pre-approve an autogenous connective tissue graft. You say that if you don't have this procedure you may have teeth fall out. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgery consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a surgery consultation. You say that the in-network providers have had no success in treating your pain or determining what is causing your pain. 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 surgery consultation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neurostimulator treatment.
You asked the Plan to pre-approve Neurostimulator treatment. 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 follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as therapies for the relief of chronic intractable pain under specific circumstances. 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 Neurostimulator treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence-based indication for this procedure. The request is deemed 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 Neurostimulator treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Neurostimulator treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on March 29, 2021.
You asked the Plan to pay for the bone replacement graft. You say that you believed these services from this provider would be covered by your Plan. The Plan denied your request. The Plan says they have agreed to cover some services as in-network; however, the bone replacement graft for ridge preservation is not covered under normal circumstances.
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 pay for the bone
replacement graft for ridge preservation (D7953) provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Presbyopia correcting function of intraocular lens.
You asked the Plan to pre-approve a Presbyopia correcting function of intraocular lens. You say that you would like help paying for the requested item. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve a Presbyopia correcting function of intraocular lens.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional speech therapy visits (CPT code 92507), for the enrollee.
You asked the Plan to pre-approve additional speech therapy visits. You say that the enrollee needs additional speech therapy visits. The Plan denied your request. The Plan says the enrollee has made no material gains and has unchanged physical and cognitive deficits. The Plan states the unique and sophisticated skills of a speech therapist are not required to continue to treat this condition. The Plan states this enrollee appears to be at their highest level of function realistically attainable and within the context of the disability.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional speech therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient speech therapies and should be independent with a home exercise program. There is no documentation of a decline in function. The enrollee is tolerating an oral diet. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are 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 additional speech therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional speech therapy visits (CPT code 92507), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse periodic oral evaluation (D0120) prophylaxis (D1110)
provided March 11, 2021.
You asked the Plan to reimburse the dental services. You say that please process the clam and refund as soon as
possible. The Plan denied your request. The Plan says the claim was processed with the correct out of network
cost share 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 50% for
dental services received out of network.
You have been asked to pay $115.50 for the dental services. The health plan contract says that benefits
received out of network are subject to any in network benefit maximus, limitations, and/or exclusions. You
may be billed by the out of network provider for any amount greater than the payment made by the Plan to the
provider. The services fall within the Dental services 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 reimburse periodic oral evaluation (D0120) prophylaxis (D1110)
provided March 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee is a fall risk. The Plan denied
your request. The Plan says the enrollee no longer requires skilled services.
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.
Continued SNF services beyond September 1, 2021, were requested. 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 continued services. Our physician reviewer found that the enrollee is
walking using a two-wheeled walker at a supervision assist level. She is at supervision for transfers and
supervision for most activities of daily living. She was reported to be medically stable. The enrollee does not
require skilled nursing services. Although the enrollee requires skilled therapy services, she does not require
services on an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthroscopy of the knee joint.
You asked the Plan to pre-approve arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877). You say that the enrollee's knee pain is worse now than before surgery. The Plan denied your request. The Plan says that the enrollee has no articular cartilage so the removal or shaving of the knee joint cartilage is not medically necessary.
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 arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found sufficient documentation is evident regarding pathology of the right knee that would benefit from the requested surgical procedure. This includes plausible scarring resulting in pain, incomplete knee extension and functional deficit. There is compelling rationale presented and/or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877) is 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 arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877) have been met. Therefore, we decided that the Plan has to pre-approve arthroscopy of the knee joint.
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