Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to you for the enrollee for a nursing facility consultation.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says a network provider can provide the requested 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 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 to you for the enrollee for a nursing facility consultation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a referral is required before you receive services from out-of-network specialists.
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 February 6, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional extraction of an erupted tooth or exposed root provided on December 6, 2019.
You asked the Plan to pay for the additional extraction of an erupted tooth or exposed root. You say that you are asking for medical consideration because you fell and needed dental aid. You also say that because you sheared the teeth off under your existing bridge, you had to have those teeth extracted and a partial built. The Plan denied your request. The Plan says benefits for this service had been satisfied and the frequency limitation had been exceeded.
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, extractions are limited to two procedures per calendar year. The record shows that you received three extractions on December 6, 2019, two of which were covered by the Plan, and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the additional extraction of an erupted tooth or exposed root provided on December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 rulesto 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's hospital course was complicated by C.diff. The documentation supports that the enrollee still requires acute level of care hospital services. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retainer crown provided on January 31, 2020.You asked the Plan to pay forthe retainer crown. You say that you are wondering how the benefit was exhausted. You say that you have no evidence the Plan has paid anything.The Plan denied your request. The Plan says after the annual maximum is exhausted, any remaining charges are your responsibility.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 is only obligated to pay $1,000 for your covered dental services annually. The records show that the Plan paid $1,000 for services received on January 31,2020. Therefore, we decided that the Plan does not have to pay forthe remaining retainer crown provided on January 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve Xolair. You say that the enrollee has tried and failed alternatives. The Plan denied your request. The Plan says there is no evidence of specific allergic sensitivity.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Xolair. Our physician reviewer found that the enrollee has a history of asthma and GERD. Her medications include Symbicort, Ventolin, and Singulair. In this case, Xolair is not FDA-approved for the enrollee's diagnosis. The use of this medication presently is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested drug 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 Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medical services provided on February 4, 2020.
You asked the Plan to waive the cost share for the services provided. You say that you should not have to pay for a follow-up visit. The Plan denied your request. The Plan says you are responsible for the copay 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).
The file shows that you received services at an urgent care facility. You were charged a $35 copay. The services fall within the urgently needed services benefit category.
You received specialist physician services on the date of service at issue. You were charged $22.15. Because the amount is less than your $35 copay, you were charged the lesser amount. The services fall within the physician services benefit category. 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 cost share for the medical services provided on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system (33289, C2624).
You asked the Plan to pre-approve the CardioMEMS system. You say that the device is medically necessary. The Plan denied your request. The Plan says the device is considered investigational in this application.
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 CardioMEMS system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 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 CardioMEMS system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS system (33289, C2624).
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 the Plan's denial reasoning is incorrect. You say that the requested orthotics will be used inside of the enrollee's regular footwear. You asked the Plan to reconsider providing coverage for the requested orthotics. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.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 suchcriteria 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 is noted to have osteoporosis, for which she has previously taken raloxifene and alendronate. The enrollee appears to have responded well to the alendronate, but couldnot tolerate it and therefore stopped taking it. She has not tried and failed the Plan's required drug of Reclast. There is no documentation to support that the required drug would be contraindicated or less effective; 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-approveProlia
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration
because the member is not able to see their doctors due to COVID 19. The Plan denied your request. The Plan
says the medical records did not show that the member was confined to her home and there was no
documentation showing that she continues to have a medical problem that needs special care that only a skilled
person can do.
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 home health services. Our reviewer
says that the records do not show that skilled nursing services are required to effectively provide treatment,
care, and/or services in order to improve the member's condition, to establish/perform a maintenance program
to maintain the member's condition and/or prevent deterioration. Our physician reviewer found The member
does not have complex wound care, new enteral feedings. She has been educated on her condition. Her medical
conditions are chronic and stable. She does not require the ongoing skills of a professional skilled nurse.
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 home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health services.
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 your brother found you unresponsive and so he called 911. You say that the emergency responders discovered that your blood sugar levels were extremely low and administered an IV. You stated that after your blood sugar levels were restored you elected not be transported to the hospital. You say that you would have died if the ambulance had not come and you thought you were doing the responsible thing. 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 February 25, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveeight additional occupational therapy visits for the enrollee.You asked the Planto pre-approvethe additional visits. You say that this is medically necessary.The Plandenied your request. The Plansayscontinued therapy consists of range of motion exercises, which is not a skilled service.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 additional visits. Our reviewer says that the requested additional visits are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has a contracture in the RUE and range of motion exercises do not need an additional 8 supervised therapy sessions. The enrollee is distractible and her ADL tasks are not being addressed other than eating which is at a CGA level. The records do not indicate she requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not needto safely and effectively be performed only by a therapist, or under the supervision of a therapist. The enrollee/staff can have training with the 2 approved therapy sessions and do not need the additional 8 sessions of supervised therapy for this enrollee's functional level. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 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 the additional visits have not been met.Therefore, we decided that the Plandoes not haveto pre-approveeight additional occupational therapy visits for the enrollee.
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 you woke your spouse up on the date of
service due to an insulin reaction that you were experiencing. You stated that you were unconscious and
shaking so your spouse called 911 for assistance. You say that when the ambulance responders arrived they
administered an IV and your blood sugar levels went back up within minutes. You stated that after treatment
you felt normal and were able to answer all of the responder's questions appropriately. You say that you did not
feel like you needed to go to the hospital and you were told by the responders that the hospital probably would
not be able to do much more for you. You stated that it was agreed that you did not need to go to the hospital
and so the emergency responders left. You say that the ambulance services were medically necessary and if
you had gone into a diabetic coma you may not have woken back up. You asked the Plan to reimburse you for
the cost of the ambulance services. 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 December 23, 2017. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided October 3, 2019.You asked the Plan to pay for the dental services. You say that this cleaning was part of the 4 times yearly prophylactic maintenance scheduled every 3 months that you have been receiving at your dentist's office since 2008.The Plan denied your request. The Plan says this service is 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 pay for the periodontal maintenance (D4910) provided October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided February 6, 2020.You asked the Plan to pay forthe dental services. You say that the enrollee has been receiving periodontal maintenance cleaning every 3 months since 2016. The plans fax back about periodontal cleaning coverage is deceiving.The Plan denied your request. The Plan says this service is 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. Procedures not listed under the Description of Benefits is not covered by the plan.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 forthe periodontal maintenance provided February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea stair lift.You asked the Plan to pre-approvea stair lift. You say that you are having hip surgery and the requested stair lift is medically necessary for you. You say that you cannot climb stairs due to your multiple medical issues. You stated that you are a high-risk person because of the current pandemic and your only option to live is where you sleep upstairs. You say that you have no options and you asked the Plan to reconsider providing coverage for the requested stair lift.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea stair lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can have care at home or at a skilled nursing facility.
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. You are currently undergoing treatment at an acute care hospital (ACH) for sacral osteomyelitis in the setting of spina bifida. You are receiving a prolonged course of antibiotics. You are is not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.