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

We decided that the Plan does not have to pay for the consultation (D9310) provided on January 12, 2021.
You asked the Plan to pay for the dental service. You say that the dentist's office did not give you any kind of a plan that would have been a consult. You say that the dentist had the staff take an x-ray and you were told that your tooth needed to be pulled. You also say that you feel you should not have to pay for this. The Plan denied your request. The Plan says consultation is not listed as a covered service.
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 consultation (D9310) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the low vision aid fitting (92354) you received on October 22, 2020.
You asked the Plan to pay for the fitting. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Medicare does not cover low vision aids, and by extension, does not cover the fitting for low vision aids. Therefore, we decided that the Plan does not have to pay for the low vision aid fitting (92354) you received on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on December
15, 2020.
You asked the Plan to waive the copayment for lab test. You say that your plan indicates that you have a $0
copayment for this. The Plan denied your request. The Plan says the copayment amount you are being charged
is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $5
copayment for in-network lab test.
You have been asked to pay $5 copayment for lab test. Lab tests 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
laboratory testing provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the auricular peripheral nerve stimulator (PNS).

You asked the Plan to pre-approve the PNS device. You say that this is medically necessary as other treatments have been less successful. The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that auricular PNS is not covered by Medicare as it is not considered medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the auricular peripheral nerve stimulator (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is to treat and heel the pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational and the enrollee may have a contraindication to this procedure.

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. 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 its safety and efficacy. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.

You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says Medicare only covers this procedure when the member is enrolled in a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion Interspinous device. 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 and more research is needed to show its safety and efficacy. 

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 Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mycophenolate mofetil 500mg tablet medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this
medication.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B as this drug is not being used to prevent organ transplant rejection. Therefore, we decided that
the Plan does not have to pre-approve the mycophenolate mofetil 500mg tablet medication.
Benefits for this medication 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 pay for the subsequent nursing facility care provided on October 27, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like these charges to be reconsidered for payment. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
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 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 subsequent nursing facility care provided on October 27, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on January 25, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a shingles vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on January 25, 2021.
Benefits for the shingles vaccine 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: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you require rehab. The Plan denied your request. The Plan says that that your primarily have custodial needs and do not require daily skilled therapy.
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 skilled nursing facility (SNF) services are medically reasonable and necessary. You do not have documented skilled nursing needs. You do have documented skilled therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare criteria for SNF services We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services.
You asked the Plan to pay for the transportation services. You say that you require this service in your
wheelchair to your physicians. 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 wheelchair van transport
services.
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided
that the Plan does not have to pay for the transportation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted for a postoperative wound infection and is receiving intravenous antibiotics and being treated with a wound vac. The antibiotics stop on June 2. The record does not indicate the enrollee is anticipated to need LTACH services for at least 25 days. The enrollee continues to receive acute care services that have not been denied. The medical record does not indicate that the enrollee requires services she is not currently receiving but that would be available at the LTACH. The elements of the coverage criteria 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva Respimat aerosol.
You asked the Plan to pre-approve Spiriva Respimat aerosol. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Spiriva Respimat aerosol is not covered under the enrollee's Medicare Part B benefit.
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 Spiriva Respimat aerosol.
Benefits for Spiriva Respimat aerosol 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) and osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) provided November 16, 2020 and December 2, 2020.
You asked the Plan to pay for the bone replacement graft and osseous surgery. You say that you have the platinum plan and expected that it would cover major dental procedures at least in part. The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for the bone replacement graft for ridge preservation - per site (D7953) and osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) provided November 16, 2020 and December 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram rendered on February 2, 2021.
You asked the Plan to waive the copayment for these services. You say that you had to have another exam due to one film looking suspicious. The Plan denied your request. The Plan says the copayment was 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 $40 copayment for Medicare-covered x-ray and ultrasounds.
Review of the file shows that you received a diagnostic mammogram on February 2, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered x-ray and ultrasounds 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 mammogram rendered on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve observation care for the enrollee.
You asked the Plan to pre-approve observation care. You say that observation care for further evaluation is medically necessary. The Plan denied your request. The Plan says that medical necessity for observation care has not been established.
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 observation care. Our reviewer says that medical necessity has been established for observation care. Our physician reviewer found the enrollee is a 72-year-old female who presented with confusion and weakness, which was chronic. She also complained of abdominal pain. The enrollee expressed homicidal ideation and delusional thoughts with impaired cognition upon evaluation. The enrollee showed weakness with low blood pressure warranting observation status to treat with hydration. Therefore, the requested observational care is medically reasonable and necessary considering the enrollee's clinical situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of observation care have been met. Therefore, we decided that the Plan has to pre-approve observation care for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 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 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 services provided by an out-of-network provider on December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane.
You asked the Plan to pre-approve Abraxane. 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 Abraxane. Our reviewer says that the documentation does not support that the enrollee meets step therapy criteria. Our physician reviewer found the enrollee is newly diagnosed T4N3MO squamous cell cancer of the right upper lung (NSCLC). The Plan requires a trial of docetaxel or paclitaxel before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's 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 Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane.