Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2331) and core buildup, including any pins when required (D2950) provided on December 30, 2020.
You asked the Plan to pay for the resin-based composite and core buildup. You say that your benefits were not exhausted at this time. The Plan denied your request. The Plan says your annual maximum benefit had been exhausted.
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 Plan offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on December 30, 2020 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2331) and core buildup, including any pins when required (D2950) provided on December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
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 requested bone marrow aspirate is considered experimental in nature. More research is needed to show safety and efficacy. The iliac crest bone graft is the gold standard for bone grafts. The bone marrow aspirate 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 bone marrow aspirate.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 direct skilled nursing services of a RN.
You asked the Plan to pre-approve the direct skilled nursing services of a RN. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 direct skilled nursing services of a RN. Our reviewer says that ongoing home health RN services are not shows to be medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. 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 direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 direct skilled nursing services of a RN.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve Brovana. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been 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 Brovana. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found that the enrollee is a 73-year-old man with a diagnosis of chronic obstructive pulmonary disease, unspecified. The case file does not contain documentation of trial and failure of the Plan's preferred drug Perforomist. In addition, the file does not indicate that Perforomist would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve follow-up Computed tomography (CT).
You asked the Plan to pre-approve follow-up CT thorax; without contrast material (71250). You say that the enrollee needs a follow-up CT. The Plan denied your request. The Plan says it has not been 6 months since the last CT scan.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 follow-up CT thorax; without contrast material (71250). Our reviewer says that the CT is not medically necessary. Our physician reviewer found a CT scan in November demonstrated suggested follow up in 6 months. The scan was requested at four months. The documentation submitted does not indicate a medical rationale why the scan is requested earlier. The medical reasonableness and necessity of the requested service at this time is not demonstrated. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of follow-up CT thorax; without contrast material (71250) have not been met. Therefore, we decided that the Plan does not have to pre-approve follow-up Computed tomography (CT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Ilumya. Our reviewer says that the
documentation does not support that the enrollee meets step therapy criteria for the requested drug. Our
physician reviewer found the enrollee has psoriasis vulgaris. The enrollee has failed topical treatments and
Otezla. The documentation does not support that the enrollee has tried and failed Remicade or Inflectra and
Stelara. The documentation does not support an indication that the step therapy required drugs would likely be
less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete mandibular denture (D5120).
You asked the Plan to pre-approve complete mandibular denture. You say that this service is medically necessary. The Plan denied your request. The Plan says your benefit has been exhausted for the 2021 plan year.
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 complete mandibular denture once every five years. We looked at the file and Medicare rules. The file indicates you last received this service in 2019. Five years have not passed since this service was received. Based on this information, we decided that the Plan's rules for coverage of complete mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-approve complete mandibular denture (D5120).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 10, 2019.
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 IRF care is the best option for the enrollee's recovery. The Plan denied your request. The Plan says criteria are not met for the IRF level of care.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve non-emergency transportation (A0130, T2005).
You asked the Plan to pre-approve the transportation. You say that you were authorized for the surgery but was not provided authorization for the transportation. You need assistance with a wheelchair accessible form of transportation. The Plan denied your request. The Plan says that routine transportation is not a covered benefit under the health plan.
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 48 one way trips per year within 30 miles from pick-up location. 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 the transportation have been met. Therefore, we decided that the Plan has to pre-approve non-emergency transportation (A0130, T2005).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for the enrollee's condition.
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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before this service can be approved for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by a Medicare opt-out provider on August 13, 2020.
You asked the Plan to pay for the services. You say that your previous insurance reimbursed you for these services. The Plan denied your request. The Plan says you are responsible for services from privately contracted provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided by a Medicare opt-out provider on August 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a PICC provided on September 23, 2020.

You asked the Plan to pay for the PICC insertion. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the insertion of a PICC provided on September 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve Inpatient Rehabilitation Facility (IRF) care.
You asked the Plan to pre-approve the Inpatient Rehabilitation Facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
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 failed to provide the original medical records used to make their determination. The records are from contract providers. Without this documentation, the denial is not supported. Therefore, we decided that the Plan has to pre-approve Inpatient Rehabilitation Facility (IRF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on December 8, 2020.
You asked the Plan to pay for the periodic oral exam and prophylaxis. You say that you are entitled to 3 dental cleanings per year. You also say that Plan representatives also confirmed this. The Plan denied your request. The Plan says these services exceed the frequency limitations in your benefit plan. The Plan also says that your call history was reviewed, and it was and verified that you were not given any misinformation about the services in question.
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, periodic oral exam (D0120) and prophylaxis (D1110) are each limited to two procedures per plan year. The record shows that you received periodic oral exams (D0120) and prophylaxes (D1110) on February 26, 2020, and July 29, 2020 and your periodic oral exam (D0120) and prophylaxis (D1110) benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GelOne injections.
You asked the Plan to pre-approve GelOne injections. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted records do not show that the criteria for coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the patient has failed at least three months of conservative therapy. We looked at the file and Medicare rules. The submitted medical records do not document at least 3 months of conservative therapy. Based on this information, we decided that Medicare rules for coverage of GelOne injections have not been met. Therefore, we decided that the Plan does not have to pre-approve GelOne injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 additional physical therapy (PT) visits.

You asked the Plan to pre-approve these services. You say that you need PT due to your injuries. The Plan denied your request. The Plan says 18 visits are approved and 18 further are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have been receiving PT for a fall injury, neck and back pain, pinching of nerve roots in the spine (radiculopathy), and difficulty walking. The 18 further visits are not generally accepted as specific and effective therapy for your condition. The records show that you have made mild improvement with therapy and further PT beyond the 18 approved visits does not appear to be likely to achieve any significant improvement. You do not require the unique skills of a professional therapist to safely and effectively provide treatment. The services are not part of a maintenance program and are not needed to establish a home exercise program, maintain your current condition, or prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 additional physical therapy (PT) visits.