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

 
We decided that the Planhasto pre-approvea bone growth stimulator for the enrollee.You asked the Planto pre-approvethe stimulator. You say that this is medically necessary.The Plandenied your request. The Plansaysthatbased on the Medicare guidelines about the information received about the enrollee's condition, the enrollee does not meet the requirements.The Plan must follow Medicare rules. The rules say that an electrical bonegrowth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with theelectrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve the stimulator. Our reviewer says that the requested stimulator is medically reasonable and necessary. Our physician reviewer found the enrollee underwent L4/5 decompression laminectomy, left sided facetectomy, L4/5 posterior lumbar interbody fusion, and bilateral posterolateral fusion at the L4/5 level on 4/22/20. Comorbidities included hypertension, rheumatoid arthritis, bronchitis, liver disease, anemia, history of alcoholism, and stroke. Shewas a current smoker documented as 1 to 2 packs per day. Under consideration is a request for a bone growth stimulator following surgery due to risk factors for failed fusion. Current evidence based medical literature indicates that bone growth stimulation has a positive effect on fusion for patients under the age of 60 and patients who use tobacco. In this case, due to the combination of risk factors, this request is indicated as a relative exception to Medicare criteria. Therefore, this request for an electrical bone growth stimulator would be considered medically reasonable and necessary for this 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 the stimulator have been met.Therefore, we decided that the Planhas to pre-approvea bone growth stimulator for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a caseagain if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea rowing machine (E1399).You asked the Plan to pre-approvethe rowing machine. You say that the machine is medically necessary.The Plan denied your request. The Plan says this 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 item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea rowing machine (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that your current partial is broken, 
you are in pain and cannot eat, and need another partial. The Plan denied your request. The Plan says this 
service exceeds the maximum count allowed per period. 
 
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, maxillary partial dentures are limited 
to one procedure every five plan years. The record shows that you last received a maxillary partial denture on 
September 9, 2019, and your maxillary partial dentures benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on April 27, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services provided by a specialist in an outpatient setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $45 copayment for specialist services. In this case, we looked at thefile, the Plan's contract and Medicare rules. The file shows that you received specialist services on April 27, 2020. You have been asked to pay a $40 copayment for the specialist office visit, which is less than the contracted $45 copayment amount. The specialist office visit falls within the Physician/Practitioner services 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 forthe specialist office visit provided on April 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveModafinil for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare says Part B programs can only provide limited benefits for prescription drugs.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 Plandoes not haveto pre-approveModafinil for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approvea Breo Ellipta 100-25 mcg InhalerYou asked the Plan to pre-approveBreo Ellipta inhaler. You say that the medication is medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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-approvea Breo Ellipta 100-25 mcg InhalerBenefits for Breo Ellipta inhalermay be available under Medicare Part D.Contactthe 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 forthe additional intraoral x-ray and additional re-cement or re-bond crown provided on May 18, 2020.You asked the Plan to pay forthe additional intraoral x-ray and additional re-cement or re-bond crown. You say that this was the onlydentist you found that was open. You say that you needed help right away to cover this medical emergency.The Plan denied your request. The Plan says the claim was reprocessed to reflect your in-network 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, you also have a maximum benefit of one intraoral x-ray every year and one re-cement or re-bond crown every five years.Therefore, we decided that the Plan does not have to pay forthe additional intraoral x-ray and additional re-cement or re-bond crown provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve cold pad. You say that you are having surgery on both of your knees and 
this is a major part of managing the pain post-operation. The Plan denied your request. The Plan says the denial 
of authorization for this item is correct, because this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump is not 
covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cold pad have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
fluid circulating cold pad with pump.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan does not have to pay for the monthly golf membership provided from July 21, 2018 to
March 21, 2020.
You asked the Plan to pay for the monthly golf membership provided from July 21, 2018 to March 21, 2020.
You say that these fees should be covered by the Plan. The Plan denied your request. The Plan says golf
membership is not covered under the Plan benefit. We partially overturned the Plans denial. The Plan
requested a reopen and stated that we did not apply the correct benefit criteria.
The Plan is correct in this case. The rules say that Medicare does not cover gym benefits. Neither Medicare nor
the Plan covers fees such as golf memberships. Therefore, we decided that the Plan does not have to pay for the
monthly golf membership provided from July 21, 2018 to March 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe compression pump and garments (E0652, E0667) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe compression pump and garments. You say that the device is medically necessary.The Plan denied your request. The Plan says there are network providers available.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 isnot 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-approvethe compression pump and garments (E0652, E0667) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic surgical shoe. 
 
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 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 a therapeutic surgical shoe.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core buildup, including any pins when required for tooth #19 provided on May 15, 2020.You asked the Plan to pay forthe core buildup. You say that you received a core buildup due to a root canal.The Plan denied your request. The Plan says you are limited to one crown every five years per tooth, including core buildup and post and core.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, benefits for this service can only be provided once every five years. The record shows that you last received a core buildup on tooth #19 on August 6, 2019, and your core buildup benefit for tooth #19 has been exhausted.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required for tooth #19 provided on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive coinsurance for a CPAP machine provided by a participating provider on March 13, 2020.You asked the Plan to waive coinsurance for a CPAP machine. You say that you did not request this equipment and either did your doctor. The Plan denied your request. The Plan says the correct coinsurance has been applied.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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for a CPAP machine.The total allowed amount is $43.33. The total amount you are being asked to pay is $8.67 ($43.33 x 20% = $8.67). A CPAP machine falls within the durable medical equipment 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 coinsurance for a CPAP machine provided by a participating provider on March 13, 2020. We note your complaint about not requesting this equipment. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is 
experimental/investigational and non-covered. 
 
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 procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Food & Drug Administration (FDA) indications include implantation of the 
Vertiflex device at 1 or 2 adjacent lumbar levels in patients with moderate stenosis in whom operative 
treatment is indicated at no more than 2 levels. The enrollee has severe central canal stenosis noted at L3/4 and 
L4/5 which is not an FDA covered indication. There is no rationale why standard surgical decompression 
would not be indicated. This device has not been studied in patients with active rheumatoid arthritis. FDA 
contraindications include osteoporosis, which has not been adequately addressed in the medical records. There 
is no discussion indicating that a dual-energy X-Ray absorptiometry (DEXA) scan has demonstrated no 
osteoporosis in the enrollee. Insertion of the Vertiflex device at L3/4 and L4/5 would not be considered the 
standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as 
medically reasonable and necessary for treatment of the enrollee's medical condition. 
 
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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A4520). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these because you cannot 
walk without assistance and it is difficult to make it to the restroom. 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 incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520).
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-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea stair lift
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral facet injection at L4-S1 for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says a medical branch block may be repeated if the first injection results in significant relief 
for at least three months. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has two months of pain relief from the first set of blocks. On the second set of blocks, the 
pain increased. The increase in pain after the second block fails to meet the criteria of the LCD. Therefore, the 
request is deemed not medically reasonable or 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bilateral facet injection at L4-S1 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the resin-based composite. We decided that the Plan does not have to 
pay more for the limited oral evaluation, endodontic therapy and cone beam CT capture.  
 
You asked the Plan to pay more for the limited oral evaluation, endodontic therapy, cone beam CT capture and 
resin-based composite. You say that you were referred for further evaluation and treatment. You say that 
additional payment for the services should be made. The Plan says that the claim processed correctly. 
 
  
We decided that the Plan has to pay for the resin-based composite (D2391).  
 
The Evidence of Coverage clearly lists a resin-based composite (D2391) as a covered benefit with 20% 
coinsurance. Therefore, we decided that the Plan has to pay their share of the cost for the and resin-based 
composite.  
 
We also decided that the Plan does not have to pay more for the limited oral evaluation, endodontic 
therapy and cone beam CT capture. 
 
The records show the Plan paid the allowed amount for the limited oral evaluation and 50% of the allowed 
amount for endodontic therapy. The cone beam CT capture applied $99 to the annual deductible. You are 
responsible for the difference between the billed and allowed amount for dental services from an out-of-
network provider. This means that the Plan paid the correct amount for these services. Therefore, we decided 
that the Plan does not have to pay more for the limited oral evaluation, endodontic therapy and cone beam CT 
capture. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on September 6, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray provided on September 6, 2019 by an out 
of network (OON) provider.