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

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the enrollee cannot sleep on a regular mattress due to health issues. The Plan denied your request. The Plan says the enrollee does not have pressure wounds.
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. The record does not show the enrollee has pressure ulcers. Based on this information, we decided that Medicare rules for coverage of a powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional resin-based composite.
You asked the Plan to pre-approve the additional resin-based composite. You say that your contract entitles you
to one resin filling per year but does not state how many sides of one tooth can be filled. You also say that you
feel this service is allowed under your plan. The Plan denied your request. The Plan says you have received
approval for one dental filling. The Plan also says that there is no benefit for additional dental fillings.
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, resin fillings or restorations are limited
to 1 procedure per year. The record shows that you were approved for one dental filling on April 21, 2020 and
your resin filling or restoration benefit has been exhausted. Therefore, we decided that the Plan does not have
to pre-approve the additional resin-based composite.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for use with interstitial continuous glucose monitoring coded with A9276.
You asked the Plan to pre-approve the sensor. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and code A9276 is used to describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve a sensor for use with interstitial continuous glucose monitoring coded with A9276.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diapers, pads, gloves, and cream.
You asked the Plan to pre-approve incontinence supplies. You say that you need these supplies and cannot afford them. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. Disposable supplies are not covered. MA plans may offer as a supplemental benefit health-related items and medications that are: available without a prescription, and are not covered by Medicare Part A, Part B or Part D. You do not have a supplemental benefit. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Disposable supplies and over-the-counter creams are not covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve diapers, pads, gloves, and cream.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the radiation therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not have out-of-network coverage unless the services are urgent or cannot be provided 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 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 medical services to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis with no reported history of osteoporotic fracture. She has not tried and failed the Plan's required drug of zoledronic acid. The records do not show that the required drug would be less effective or contraindicated; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on June 5, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for these services was not filed until December 16, 2019. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the services rendered on June 5, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence wipes.
You asked the Plan to pre-approve incontinence wipes. You say that you need these supplies and cannot afford them. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve wipes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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. 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 medical services provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee has complications with his blood sugar. You say that on the dates of service, the enrollee began to show indications that his blood sugar was getting low. The paramedics were called and they provided treatment. You say that it was determined that the enrollee did not need transport as he was feeling better and he did not want to go to the hospital. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 9, 2020 and February 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from December 24, 2018, to December 27, 2018.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee's condition was stabilized prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 the inpatient care. Our reviewer says that the requested post-stabilization care was not medically reasonable and necessary. Our physician reviewer found that the enrollee was stable for transfer to an in-plan facility at the time of admission, following the ED evaluation. Any care provided after this time is post-stabilization care and therefore not covered unless pre-authorized. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from December 24, 2018, to December 27, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that your doctor won't recommend you to anyone because your doctor doesn't take your Lyme disease serious. The Plan denied your request. The Plan says there are in-network providers available for 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 has network providers available who can provide 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 physician services 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 two pairs of eyeglasses.
You asked the Plan to pre-approve the two pairs of eyeglasses. You say that you would like reconsideration because the $300 should go towards two pairs of eyeglasses. The Plan denied your request. The Plan says you are currently able to receive an eye exam with your eye doctor as well as eyeglasses or contact lenses but two pairs of eyeglasses cannot be approved.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 for eyeglasses. We looked at the file and the Plan's rules. Per the Plan, you qualify for one pair of eyeglasses. Based on this information, we decided that the Plan's rules for coverage of the two pairs of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve two pairs of eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and Freestyle Libre Sensor kit.
You asked the Plan to pre-approve the CGM and sensor kit. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria of a CGM has not been met and Freestyle is not a plan-preferred brand. Enrollees must use Accu-Chek or OneTouch glucometers.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 CGM and sensor kit. Our reviewer says that coverage criteria is not met. Our physician reviewer found there is no reason documented in the records that the enrollee cannot use a traditional glucometer and test strips. 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 CGM and sensor kit. have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and Freestyle Libre Sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for consultation and treatment.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and the enrollee can be redirected to network providers.
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 a referral for consultation and treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve these services. You say that not having the bed would impact your health. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you would like approval to see this out-of-network provider. The Plan denied your request. The Plan says the member has been approved to see an in-network orthopedic oncologist.
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 a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion of a subcutaneous cardiac rhythm monitor provided on September 4, 2019.
You asked the Plan to waive the coinsurance for the insertion of a subcutaneous cardiac rhythm monitor. You say that you disagree with the charges because you thought that the copayment would be much lower for outpatient services. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the insertion of a subcutaneous cardiac rhythm monitor on September 4, 2019. The allowed amount is $7,042.79 and 20% of that is $1,408.56. You have been asked to pay the total coinsurance amount of $1,408.5 for the insertion of a subcutaneous cardiac rhythm monitor. The insertion of a subcutaneous cardiac rhythm monitor falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance for the insertion of a subcutaneous cardiac rhythm monitor provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.
You asked the Plan to pre-approve these services. You say that the last injection helped. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have osteoarthritis of the left knee. You had a previous diagnostic genicular nerve block. Genicular nerve ablation is considered experimental/investigational in nature and is therefore not reasonable or medically necessary at this time. 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 genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic left knee pain. He had an intra-articular injection of steroids. He had two sets of diagnostic genicular nerve blocks and the request is for RFA of the genicular nerves. This procedure is considered experimental/investigational in nature and is the subject of ongoing clinical trials. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Combocare E-Stem and Ultrasound Combo Professional
Device (E1399) provided January 24, 2020 to February 23, 2020.
You asked the Plan to pay for Combocare E-Stem and Ultrasound Combo Professional Device. You say that
you are requesting a medical necessity review of the Combocare E-Stem and Ultrasound combo professional
device. The Plan denied your request. The Plan says medical necessity could not be established.
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 Combocare E-Stem and Ultrasound
Combo Professional Device. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee has one of the diagnosis codes
listed in the LCD-related Policy Article for applicable diagnoses but is not enrolled in an approved clinical
study that meets all of the requirements set out in NCD 160.27 therefore the criteria for a Combocare E-Stim
and Ultrasound professional Device 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 Combocare E-Stem and Ultrasound Combo Professional Device have not been
met. Therefore, we decided that the Plan does not have to pay for Combocare E-Stem and Ultrasound Combo
Professional Device (E1399) provided January 24, 2020 to February 23, 2020.