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

We decided that the Plan does not have to pre-approve continuous glucose monitor sensors. 
 
You asked the Plan to pre-approve continuous glucose monitor sensors. You say that you are constantly adjusting your dosage and a CGM is way more convenient. The Plan denied your request. The Plan says the records show you are not insulin injecting three or more times a day. 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 shows you are not using insulin three or more times a day and you are not on an insulin pump. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met, therefore supplies are not covered. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair attendant control, accessory tray, and mobile device charger You asked the Plan to pre-approve power wheelchair attendant control (E2331), accessory tray (E0950), and mobile device charger (K0108). You say that you need a Group 3 power wheelchair with attendant control, accessory tray, and mobile device charger. The Plan denied your request. The Plan says you are able to operate the power wheelchair on your own, and the tray and charger are items of convenience. 
 
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the option/accessory itself is medically necessary. The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The record shows you can operate the requested power wheelchair and the accessory tray and charger are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve power wheelchair attendant control, accessory tray, or mobile device charger.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for companion services (A9270) provided on January 4, 2020 through January 26, 2020. 
 
You asked the Plan to pay for the companion services. You say that you would like reconsideration because these home health services are medically necessary. The Plan denied your request. The Plan says 24 hour per day/7 days a week home health care services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the companion services have not been met. The services you are requesting in this appeal are 24 hours a day/7 day a week custodial care services. Custodial care is not a covered benefit, and the Plan covers up to 35 hours a week of home health services. Therefore, we decided that the Plan does not have to pay for companion services (A9270) provided on January 4, 2020 through January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy 3D conformation with image guided radiotherapy (IGRT). 
 
You asked the Plan to pre-approve radiation therapy 3D conformation with IGRT. You say that this is medically necessary. The Plan denied your request. The Plan says this treatment is not recommended 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 radiation therapy 3D conformation with IGRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the need for 3D radiation has not been substantiated in this case and it would be within accepted standards of care to use 2D radiation. With whole brain radiation (including prophylactic brain radiation), it is not standard to use IGRT and no plausible rationale for the need of IGRT was offered in the case records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy 3D conformation with IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy 3D conformation with image guided radiotherapy (IGRT).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 skilled nursing visits. 
 
You asked the Plan to pre-approve 10 skilled nursing visits. 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 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 10 skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested skilled services beyond what was approved by the health plan are not required to treat the enrollee's illness or injury, improve the enrollee's condition, maintain the enrollee's condition, or prevent deterioration of the enrollee's condition. The enrollee's wound care needs are not complex and she has no other 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 10 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 skilled nursing visits
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from January 6, 2020 through January 13, 2020. 
 
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 post-stabilization care. Our physician reviewer found based on the clinical documentation available in the medical record, the patient was stable to transfer by ambulance to an in-network hospital after completion of the emergency department evaluation at 4:56 AM on January 6, 2020. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from January 6, 2020 through January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature, upgraded electronics, or LED light kit. 
 
You asked the Plan to pre-approve the power seat elevation feature, upgraded electronics, and LED light kit. You say that you need a Group 3 power wheelchair with power seat elevation feature, upgraded electronics, and LED light kit. The Plan denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches. The LED light kit is not medical and the seat elevation feature 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 LED light kit and seat elevation feature do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Documentation shows that upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature, upgraded electronics, or LED light kit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 13, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on June 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and endodontic therapy to be provided by an Endodontist. 
 
You asked the Plan to pre-approve the consultation and endodontic therapy. You say that you do not want the tooth to be extracted, and would like to have a root canal. The Plan denied your request. The Plan says consults and extractions provided by Oral Surgeons, Periodontists, Endodontists, other dental specialists or non-network General Dentists are not covered. The Plan also says that dental services are only covered when they are performed by a participating general dentist. 
 
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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and endodontic therapy to be provided by an Endodontist.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 above. 
 
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you do have a need for multiple therapies, including physical and occupational therapy there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 an osteogenesis stimulator, electrical, non-invasive. 
 
You asked the Plan to pre-approve non-spinal osteogenesis stimulator, electrical, non-invasive (E0747). You say that your fracture in your foot is not healing. The Plan denied your request. The Plan says it has not been nine months since your surgery. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for failed fusion after nine months has elapsed. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file shows that at the time of your request it had not been nine months since your surgery. Therefore, we decided that the Plan does not have to pre-approve an electric osteogenesis stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two extractions to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extractions. You say that you have a heart condition, are also a diabetic, and need your teeth extracted. You also say that this may affect your health condition. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered. 
 
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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve the two extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-three surfaces, anterior teeth 8, 9 (D2332) and porcelain crown teeth 8, 9 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that why are your dental requests not covered if it says they are covered in the 2020 Healthcare benefits book. You called 3 times to find out what your benefits were and got 3 different answers. The Plan denied your request. The Plan says these services are not covered under the plan 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 resin-three surfaces, anterior teeth 8, 9 (D2332) and porcelain crown teeth 8, 9 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reline complete maxillary denture (laboratory) teeth 116 (D5750) mandibular partial denture (D5214) tooth 17 and prophylaxis (D1110). 
 
You asked the Plan to pre-approve the dental services. You say that you were never informed of a $1000 yearly cap. You are legally blind and relied on a customer service agent that you spoke with to educate you on your benefits. The Plan denied your request. The Plan says the services are covered benefits but the annual maximum has 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. The health plan contract says that once the $1,000 annual maximum has been exhausted any remaining charges will be your responsibility. 
 
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 at this time. Therefore, we decided that the Plan does not have to preapprove reline complete maxillary denture (laboratory) teeth 1-16 (D5750) mandibular partial denture (D5214) tooth 17 and prophylaxis (D1110).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 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 above. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee does require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is consistent documentation that the enrollee can be expected to tolerate intensive rehabilitation services. There is a reasonable expectation that this enrollee 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha Sureclick.. You say that it is your medical opinion that the enrollee is eligible for Repatha therapy. You also say that you would like the enrollee on Repatha therapy to reduce her low-density lipoprotein (LDL). The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.
Benefits for Repatha Sureclick. may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says an inpatient skilled nursing facility admission 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 above 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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appears appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing test, tympanometry and binocular microscopy provided on December 4, 2019. 
 
You asked the Plan to waive the copayment for the hearing test, tympanometry and binocular microscopy. You say that you did not request the procedures you are being charged for. You say that you shouldn't be held responsible for this bill. The Plan denied your request. The Plan says the copayments applied correctly. 
 
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 $35 copayment per basic hearing and balance exam performed by an in-network specialist and a $15 copayment for other outpatient diagnostic tests from an in-network provider.  
 
You have been asked to pay a total of $65 for the hearing test, tympanometry and binocular microscopy.  
 
Service Allowed Amount Standard Copayment Member Liability Hearing Test $41.47 $35 $35 Tympanometry $15.89 $15 $15 Binocular Microscopy $32.56 $15 $15 TOTAL:   $65 The hearing test falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The tympanometry and binocular microscopy fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 copayment for the hearing test, tympanometry and binocular microscopy provided on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methscopolamine Bromide. 
 
You asked the Plan to pre-approve the Methscopolamine Bromide. You say that the enrollee continues to do well with Pamine 2.5 mg daily and dietary modifications. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methscopolamine Bromide.  
 
Benefits for Methscopolamine Bromide may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.